Renal Supportive Care – “Setting the scene”

1. Kelly Li, Nephrologist and Palliative Medicine Trainee Frank Brennan Palliative Care Consultant, Department of Nephrology St George Hospital Sydney Renal Supportive Care Master Class, Sydney, August 2015 Renal Supportive Care – “Setting the scene”

2. The nature of Nephrology • The nature of Palliative Care • What possible interface exists between the two disciplines ? • The scope of Renal Supportive Care • An overview of the Master Class

3. A tale of two specialties

4. The scope and responsibility of the discipline of Nephrology

5. What nephrologists do... • When I first entered nephrology: • BP <140/90 • ACEI reduces mortality • As many transplants as possible

6. Whilst that hasn’t changed...

7. Growing number of elderly dialysis patients • Not best transplant candidates ANZDATA registry 37th annual report

8. Growing number of elderly dialysis patients • Not best transplant candidates • Lots of comorbidities ANZDATA registry 37th annual report

9. The hardest question for nephrologists Will my patient benefit from dialysis?

10. The hardest question for nephrologists • Will my patient benefit from dialysis? • https://s-media-cache-ak0.pinimg.com/236x/99/f8/37/99f837218df3b146a2bf05314936735d.jpg

11. Dialysis is life-saving for some • http://www.china.org.cn/china/2013-01/21/content_27747038.htm

12. Newer and better machines • http://health.clevelandclinic.org/wp-content/tn3/0/artifical-kidney-dialysis.jpg • https://www.fresenius.com/images/Dialysis_machine.jpg

13. But is dialysis for everyone with ESKD?

14. But is dialysis for everyone with ESKD? Limited or no benefit for some?

15. Murtagh F et al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. NDT (2007) 22: 1955–1962

16. Dialysis in Frail Elders — A Role for Palliative Care Robert M. Arnold, M.D., and Mark L. Zeidel, M.D.

17. Kurella et al. Functional status of elderly adults before and after initiation of dialysis. NEJM 2009;361:1539–47

18. Does everyone who has ESKD commence dialysis ?

19. In Australia, for every one patient with ESKD receiving Renal Replacement Therapy (RRT) there is another who does not receive RRT Australian Institute of Health and Welfare Research, 2011

20. For those who don’t go on dialysis • How do we look after these patients? • Can we still help? • What are the care needs? • What supports are there?

21. “What will happen to me if I don’t start Dialysis ?”

22. CKD conservative management

23. CKD conservative management NOT abandonment

24. CKD conservative management NOT discharge to Palliative Care

25. If this is being raised as an option : What does a Conservative pathway mean ? What is its content ? Can we make predictions about their course ?

26. Challenge is to ensure that this pathway of management is not seen as “second best” or inadequate but is thorough, systematic and evidenced-based

27. CKD conservative management • Fluid/BP/electrolyte/anaemia • Symptom management • Psychosocial support • Advance care planning • Community palliative care • Terminal phase

28. Withdrawal from dialysis

29. Survival on dialysis ANZDATA registry 37th annual report

30. ANZDATA registry 37th annual report

31. ANZDATA registry 37th annual report

32. End of life discussions • Communication skills • Time • Preparedness • Willingness

33. The quality of dying

34. The circumstances in which patients with ESRD die varies considerably

35. If it is an expected death (eg. after the cessation of dialysis) the management of the dying phase is crucial and the manner of that dying will be remembered forever by the family

36. Symptom control

37. Nephrology clinic Nephrologist says... • Fluid restriction • Sodium restriction • Potassium restriction • Phosphate restriction • Caloric restriction • Sugar restriction (diabetics)

38. Nephrology clinic Nephrologist says... Renal patient says... • Fluid restriction • Sodium restriction • Potassium restriction • Phosphate restriction • Caloric restriction • Sugar restriction (diabetics) https://s-media-cache-ak0.pinimg.com/236x/9a/58/e1/9a58e14e0e454d25670eb91254051381.jpg

39. “Patients with CKD, particularly those with ESRD are among the most symptomatic of any chronic disease group.” Murtagh F, Weisbord S. Symptoms in renal disease.In Chambers EJ et al (eds) Supportive Care for the Renal Patient 2010, 2nd ed, OUP.

40. The dialysis unit Nephrology assessment Blood pressure Fluid status Haemoglobin Potassium Calcium/phosphate Vascular access Nutrition Cardiovascular/metabolic

41. The dialysis unit Palliative care assessment RUG ADL Problem severity scare Pain Other symptoms Psychological/spiritual Family/carer Patient rated score Difficulty sleeping Appetite problems Nausea Bowel problems Breathing problems Fatigue Pain Uraemic pruritus Restless legs

42. Saini et al. Comparative pilot study of symptoms and quality of life in cancer patients and patients with end stage renal disease. Palliative Medicine 2006; 20: 631-636

43. Saini et al. Comparative pilot study of symptoms and quality of life in cancer patients and patients with end stage renal disease. Palliative Medicine 2006; 20: 631-636

44. Do nephrology and palliative care have anything in common?

45. Nephrologists can be a little eccentric

46. The world of palliative medicine is much more civilised...

47. What is Palliative Care ?

49. WHO definition (2002) Palliative Care is an approach which improves the quality of life of patients and their families facing life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

50. Modern view of Palliative Medicine A. That Palliative Care is involved in all patients with life-limiting illnesses – not just cancer patients.