Table 1.

Policies to promote palliative care for patients with ESRD

PolicyBarrier AddressedStakeholdersExamples of Implementation
Universal screening for palliative care needsAccessNephrologists, dialysis providers, insurers, clinical organizationsScreen patients with the surprise question at dialysis initiation and at hospital admissions
Standardized symptom assessments and treatment algorithms for pain, depression, and sleep disorders
Incorporate palliative care measures in the ESRD QIPAccessNephrologists, dialysis providers, CMMSDocumentation of the advance care plan or surrogate decision maker in the medical record
Train the nephrology workforce to deliver palliative careCapacityFellowship programs, accreditation organizations, professional societiesEnhance palliative care content and assess competencies in nephrology fellowship curriculum
Emphasize palliative care training for dialysis nurses, social workers, and pharmacists
Payment reforms for palliative care servicesCapacityCMMSShared-savings model (i.e., including non-ESRD services in the “bundle”)
Concurrent dialysis and hospice care
Reimbursement for time-intensive services such as advance care planning
Fund palliative care researchEvidence baseFunding agencies, professional societiesJoint NIH/CMMS/VA funding of high-priority palliative care trials
Dedicated funding streams for junior and midcareer palliative care researchers
Multi-institution ESRD palliative care research collaboratives
  • QIP, Quality Incentive Program; CMMS, Centers for Medicare and Medicaid Services; NIH, National Institutes of Health; VA, Veterans Affairs.