Table 6.

Recommendations for end-of-life care practices in chronic kidney disease

1. Identify patients who would benefit from palliative care interventions
    a. Those who are being managed conservatively; i.e., a GFR ≤ 15 ml/min per 1.73 m2 with no dialysis.
    b. High risk of death within the next year. Consider using an integrated prognostic model (34) or the Surprise Question (17).a
2. Screen for and manage pain and other physical symptoms routinely.
    a. A simple tool such as the Edmonton Symptom Assessment Scale (ESAS) is appropriate and has been validated in CKD (3,4,35,36).
3. Screen for and manage emotional, psychosocial, and spiritual distress; refer to allied health professionals as appropriate.
    a. The ESAS is also appropriate for screening for anxiety and depression.
    b. A simple question such as “Do you have any spiritual needs or concerns that your health care providers may help address?” may be appropriate for screening for spiritual distress.
4. Assess patients' desire for prognostic information.
5. Enhance predialysis education.
    a. Educate regarding conservative care options.
    b. Education should include available palliative care and hospice services
6. Routine advance care planning (ACP). How to facilitate these discussions is described elsewhere (16,28,29,37,38).
    a. Ensure patients and families are aware of the relevance of these discussions (i.e., have an understanding of their overall health state and prognosis).
    b. Consider initiating ACP at the time that patients are being educated with respect to conservative care and renal replacement options.
    c. Include discussions of patients' goals of care, health states that the patient would no longer want dialysis, and preferred location of death.
    d. Establish a surrogate decision-maker.
    e. Ensure that family and other important people (as identified by the patient) are present for these discussions, especially the surrogate decision-maker.
7. Increase access to specialist palliative care, including hospice.
8. Provide bereavement support to patients' families where necessary.
9. Incorporate palliative care training for all nephrology fellows with an emphasis on symptom management and advance care planning.
  • a Surprise Question: “Would you be surprised if this patient died in the next 12 months?” An answer of “No” would indicate that the patient is appropriate for palliative care interventions, such as advance care planning.