Prepared by: : Dr. Robin Fainsinger

Received during: Journal Rounds on the Tertiary Palliative Care Unit, Grey Nuns Hospital

Abstract:

There has been a growing awareness of the need for palliative care teams to be more involved in patients with renal failure. This brief report presents information on patients with renal failure referred to a palliative care team over the course of one year. During this study period there were 54 referrals from the renal unit to the palliative care team. Ninety-one percent of patients were on haemodialysis. Dialysis was stopped on 25 patients during the twelve month period. The main reasons for stopping dialysis was patient choice, not tolerating dialysis, and deteriorating despite dialysis. Median time to death was seven days (0 - 17 days). Symptoms such as pain and agitation were generally well controlled with modest doses of medications. The time to death after stopping dialysis is relatively short, involvement of palliative care teams is appropriate, and symptoms in the terminal phase appear well controlled on low medication doses.

Comments:

Strengths/uniqueness:
This brief report addresses the important issue of expanding palliative care to non-malignant patient populations.

Weaknesses:
This is a retrospective study that is inevitably short on detail, open to bias, and contains some results of uncertain accuracy.

Relevance to palliative care:
This article suggests that palliative care teams can play a useful role in supporting end-of-life care in this patient population. The Edmonton Regional Palliative Care Program has recently been actively involved with an initiative of the Renal Program to develop a more comprehensive approach to advanced care planning, and supportive and palliative care for patients on dialysis.

Comparative pilot study of symptoms and quality of life in cancer patients and patients with end stage renal disease. Downloadable PDF File

Saini T, Murtagh GEM, Dupont PJ, McKinnon PM, Hatfield P, Saunders Y. Palliat Med 2006; 20: 631-36.

Prepared by: Roger Tsang

Received during: Journal Rounds on the Tertiary Palliative Care Unit, January 20, 2007

Abstract
Background: Patients with advanced renal failure are increasingly opting for conservative treatment, yet little is known of their palliative care needs.
Methods: We performed a cross-sectional study, examining symptom burden and quality of life in patients with advanced renal failure (estimated GFR <17 mL/min; n=11). A contemporary cohort with terminal malignancy acted as comparators (n=11). Symptom burden was scored using an extended Memorial Symptom Assessment Scale Form questionnaire. Quality of life was assessed using the Euroqol-a5Q questionnaire. Demographic and pathological data, performance status and co-morbidity were also recorded.
Results: Baseline characteristics were similar for the two groups. Symptom burden (renal 17; cancer 15; P-NS) and quality of life scores (renal 60; cancer 60; P-NS) were remarkably similar. Both groups reported high levels of psychological distress.
Conclusions: Patients with advanced renal failure experience a symptom burden and impairment of quality of life similar to that of patients with terminal malignancy.

Comments

Strengths/uniqueness:
- Authors embarked on a pilot study to assess expanding the role of palliative care to end organ failure
- Qualitative study using validated tools in the cancer setting
- Sound inclusion/exclusion criteria
- Solid statistical analyses
- Modified MSAS-SF to include renal symptoms as a subgroup analysis

Weaknesses:
- Small sample size (11 + 11 each arm)
- Included Stage 4 and 5 CKD, not just Stage 5
- Enrolled patients included ones who were not interested in hemodialysis but also ones who opted for dialysis
- Caucasian group - cautious to extrapolate findings across other cultural groups
- Study conducted in an outpatient setting and did not include inpatients
- Tools mostly well validated in cancer settings, less so in ESRD settings
- Hemoglobin baseline different between the two groups

Relevance to Palliative Care:
- Raises issue of increased collaboration between different physician disciplines and palliative care