In the Literature
Palliative Care in CKD: The Earlier the Better
Commentary on Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with
metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
D uring the past 2 decades, care for patients with
kidney failure treated using dialysis focused
somewhat unsuccessfully on biochemical markers as
both indicators of high-quality care and targets for
intervention. Conversely, although we have known
for a long time that dialysis patients have a high
burden of pain, depression, and other symptoms that
contribute to poor quality of life, we generally have
failed to address these issues in clinical trials or
practice guidelines, raising the question of whether
we should focus on patient symptom-centered results
rather than disease-centered approaches.
For patients with earlier stages of chronic kidney
disease (CKD), recent studies show that earlier multi-
disciplinary care emphasizing patient education and
active patient involvement in symptom management
and care plans results in improved outcomes, includ-
ing slower progression of disease and fewer complica-
tions.1-3 These studies follow the tenets of palliative
care: use of a multidisciplinary team approach that
focuses on relief of physical symptoms, addresses
psychosocial and existential-spiritual suffering, and is
sensitive to cultural differences. In nephrology, the
term “supportive care” also has been used to empha-
size this new integrative approach.4
Palliative care and multidisciplinary intervention
are associated with substantial benefits in patients in
the earlier stages of other chronic diseases.5,6 Cancer
is the most studied disease in palliative care and
presents an important parallel to CKD. In oncology,
incurable cancers increasingly are seen not as termi-
nal illnesses, but rather as chronic diseases that re-
quire chronic management strategies. Additionally,
many cancers are associated with a high symptom
burden and extensive demands on patients, including
frequent and often uncomfortable treatments and pro-
cedures. CKD, and kidney failure in particular, is very
similar in this regard, with a symptom burden as high
as most cancers, rigorous and recurrent treatments,7-10
high overall mortality rates,11 and dismal survival and
likelihood of future independence for those with the
Originally published online December 20, 2010.
Address correspondence to Michael J. Germain, MD, 100 Wason
Ave, Springfield, MA. E-mail: michael.germain@baystatehealth.
org
© 2011 by the National Kidney Foundation, Inc.
0272-6386/$36.00
doi:10.1053/j.ajkd.2010.12.001
378
poorest baseline functional status (eg, nursing home
residents).12-16 Several recent studies suggest that
patients older than 75 years with comorbid conditions
may be no more likely to survive if they choose
dialysis versus palliative nondialysis care strate-
gies.17-22 Taken in sum, these observations require us
to determine whether more invasive care necessarily
is better care. Lessons taken from a recent clinical trial
in lung cancer patients by Temel et al,6 published in
2010 in the New England Journal of Medicine, com-
paring early palliative care in conjunction with stan-
dard therapy with standard therapy alone may help us
better address this question in CKD.
WHAT DOES THIS IMPORTANT STUDY SHOW?
Temel et al6 performed a randomized controlled
trial of early palliative care integrated with standard
oncologic care versus standard oncologic alone in 151
patients with metastatic non–small cell lung cancer
from 2006-2009. The intervention included meeting
with a palliative care team soon after enrollment and
at least monthly thereafter. Patients in this integrated-
care group had statistically better quality of life,
received more hospice care, and had fewer emergency
department visits and hospitalizations, whereas pa-
tients in the standard-care group received more aggres-
sive care at end of life. Surprisingly, the integrated-
care group had significantly longer survival (11.6 vs
8.9 months). The accompanying editorial to this ar-
ticle suggests there is a paradigm shift occurring in
oncology and palliative care: no longer is palliative
care limited to patients in the active dying process, but
rather palliative care is provided much earlier in the
trajectory of the chronic disease to relieve suffering.23
For many patients with CKD, particularly the elderly,
this could occur before discussions focusing on the
appropriateness of dialysis are even required.
HOW DOES THIS STUDY COMPARE WITH
PRIOR STUDIES?
In oncology, several studies support the conclusion
of Temel et al.6 Most notably, a recent randomized
trial of 322 patients with advanced cancers showed
improved quality of life in those receiving palliative
care, although there was no change in hospitalization
rates.5 Similar findings are appreciated in both hos-
pice and nonhospice palliative-care settings.24-26 Cost
savings may be another important benefit of inte-
grated palliative-care programs.27 However, not all
Am J Kidney Dis. 2011;57(3):378-380
In the Literature
studies of palliative care have shown improved out-
comes, and palliative-care interventions are unstan-
dardized.
Despite high rates of morbidity and mortality in
patients with CKD, the integration of supportive care
in CKD remains in its infancy, with exceedingly few
studies done. What we know is that patients with
CKD want to know their prognosis, even if it is poor,
and they want to hear it from their nephrologist.28,29
Reassuringly, communicating a poor prognosis does
not result in depression or loss of hope.30 Simple
screening tools exist to help providers determine
prognosis; these include administration of a single
self-related health question to patients31or the “sur-
prise question” (“Would you be surprised if this
patient died in the next X months?”) to providers.32
The surprise question recently was validated as a
predictor of mortality for hemodialysis patients,33 and
the tool is available as an online application. Options
exist for those with poor prognoses. In a recent
controlled trial of a palliative intervention that con-
sisted of discussions with patients and families con-
cerning their symptoms and psychosocial concerns by
a team of dialysis and hospice staff, palliative care
specialists, and nephrologists, hospice use was in-
creased in dialysis patients older than 65 years with a
poor 6-month prognosis.34 We also know that patients
desire a peaceful death with control of pain and other
symptoms. They want family members with them and
want to have settled their worldly and existential
affairs. They do not want to die in the hospital. Sadly,
most deaths occur in the acute hospital setting.
WHAT SHOULD CLINICIANS AND
RESEARCHERS DO?
The Renal Physicians Association recently pub-
lished an updated guideline titled “Shared Decision-
Making in the Appropriate Initiation and Withdrawal
From Dialysis.”35 Recommendations from this guide-
line, summarized in Box 1, represent consensus ex-
pert opinion informed by ethical principles, case and
statutory law, and systematic review of the somewhat
limited existing research data. Notably, it is helpful to
put in writing the goals of care and a timeline to
readdress the care plans, especially when a trial of
dialysis is undertaken. In this situation, it is important
that the patient and family understand that if the
patient has not made a meaningful improvement in
quality of life or function or quality of life has
deteriorated beyond what is acceptable to the patient,
dialysis therapy should be withdrawn. There is an
urgent need to test these recommendations in multi-
center clinical trials to assess their effect on both
quality of life and quality of dying for patients with
Am J Kidney Dis. 2011;57(3):378-380
Box 1. How to Discuss Goals of Care With
Patients and Family
1. Honestly and compassionately discuss prognosis with the
patient and family.
2. Hold discussions as early as possible in the disease state.
3. Discuss treatment options (in addition to dialysis modalities
and transplant), such as no dialysis (conservative manage-
ment), a trial of dialysis, and withdrawal from dialysis when
suffering outweighs the benefits.
4. Institute advanced care planning, using Physician Orders for
Life Sustaining Therapies (POLST) when available.a
5. Offer aggressive palliative care and hospice as the best
treatment option when the patient has a deteriorating trajec-
tory of illness. When doing this, it is important that the patient
and family know we are not giving up or abandoning the
patient, but rather providing the best care for the current
situation.
6. Foster shared decision making. Of note, the patient and
clinician may not always agree on the treatment plan, and,
critically, the patient has the right to refuse treatment
(dialysis) while, conversely, the clinician has the right to
refuse to order a treatment (dialysis) when the expected
benefits do not justify the risks.
a
See Hickman et al36 and Citko et al.37
Summarized from the Renal Physician Association.35
kidney disease. The work by Temel et al6 in the
oncology literature suggests that we can.
Michael J. Germain, MD
Baystate Medical Center
Springfield, Massachusetts
Manjula Kurella Tamura, MD, MPH
Stanford University
Palo Alto, California
Sara N. Davison, MD
University of Alberta
Edmonton, Canada
ACKNOWLEDGEMENTS
Financial Disclosure: The authors declare that they have no
relevant financial interests.
REFERENCES
1. Hemmelgarn BR, Manns BJ, Zhang J, et al. Association
between multidisciplinary care and survival for elderly patients
with chronic kidney disease. J Am Soc Nephrol. 2007;18(3):993-
999.
2. Komenda P, Levin A. Analysis of cardiovascular disease and
kidney outcomes in multidisciplinary chronic kidney disease clin-
ics: complex disease requires complex care models. Curr Opin
Nephrol Hypertens. 2006;15(1):61-66.
3. Curtis BM, Ravani P, Malberti F, et al. The short- and
long-term impact of multi-disciplinary clinics in addition to stan-
dard nephrology care on patient outcomes. Nephrol Dial Trans-
plant. 2005;20(1):147-154.
4. Chambers E, Brown E, Germain M, eds. Supportive Care for
the Renal Patient. 2nd ed. Oxford: Oxford University Press, 2010.
379

5. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative
care intervention on clinical outcomes in patients with advanced
cancer: the Project ENABLE II randomized controlled trial. JAMA.
2009;302(7):741-749.
6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative
care for patients with metastatic non-small-cell lung cancer. N Engl
J Med. 2010;363(8):733-742.
7. Davison SN, Jhangri GS. Impact of pain and symptom
burden on the health-related quality of life of hemodialysis pa-
tients. J Pain Symptom Manage. 2010;39(3):477-485.
8. Murtagh FE, Addington-Hall J, Higginson IJ. The prevalence
of symptoms in end-stage renal disease: a systematic review. Adv
Chronic Kidney Dis. 2007;14(1):82-99.
9. Weisbord SD, Carmody SS, Bruns FJ, et al. Symptom
burden, quality of life, advance care planning and the potential
value of palliative care in severely ill haemodialysis patients.
Nephrol Dial Transplant. 2003;18(7):1345-1352.
10. Yong DS, Kwok AO, Wong DM, Suen MH, Chen WT, Tse
DM. Symptom burden and quality of life in end-stage renal
disease: a study of 179 patients on dialysis and palliative care.
Palliat Med. 2009;23(2):111-119.
11. Collins AJ, Foley RN, Herzog C, et al. Excerpts from the
US Renal Data System 2009 Annual Data Report. Am J Kidney Dis
2010;55(1 suppl 1):S1-420, A6-7.
12. Ifudu O, Mayers J, Matthew J, Tan CC, Cambridge A,
Friedman EA. Dismal rehabilitation in geriatric inner-city hemodi-
alysis patients. JAMA. 1994;271(1):29-33.
13. Jassal SV, Chiu E, Hladunewich M. Loss of independence
in patients starting dialysis at 80 years of age or older. N Engl
J Med. 2009;361(16):1612-1613.
14. Kurella Tamura M, Covinsky KE, Chertow GM, Yaffe K,
Landefeld CS, McCulloch CE. Functional status of elderly adults
before and after initiation of dialysis. N Engl J Med. 2009;361(16):
1539-1547.
15. Shlipak MG, Stehman-Breen C, Fried LF, et al. The pres-
ence of frailty in elderly persons with chronic renal insufficiency.
Am J Kidney Dis. 2004;43(5):861-867.
16. Thakar CV, Quate-Operacz M, Leonard AC, Eckman MH.
Outcomes of hemodialysis patients in a long-term care hospital
setting: a single-center study. Am J Kidney Dis. 2010;55(2):300-
306.
17. Brunori G, Viola BF, Parrinello G, et al. Efficacy and safety
of a very-low-protein diet when postponing dialysis in the elderly:
a prospective randomized multicenter controlled study. Am J
Kidney Dis. 2007;49(5):569-580.
18. Carson RC, Juszczak M, Davenport A, Burns A. Is maxi-
mum conservative management an equivalent treatment option to
dialysis for elderly patients with significant comorbid disease?
Clin J Am Soc Nephrol. 2009;4(10):1611-1619.
19. Chandna SM, Schulz J, Lawrence C, Greenwood RN,
Farrington K. Is there a rationale for rationing chronic dialysis? A
hospital based cohort study of factors affecting survival and
morbidity. BMJ. 1999;318(7178):217-223.
20. De Biase V, Tobaldini O, Boaretti C, et al. Prolonged
conservative treatment for frail elderly patients with end-stage
renal disease: the Verona experience. Nephrol Dial Transplant.
2008;23(4):1313-1317.
380
Germain, Kurella Tamura, and Davison
21. Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS,
Harris FE. Dialysis or not? A comparative survival study of
patients over 75 years with chronic kidney disease stage 5. Nephrol
Dial Transplant. 2007;22(7):1955-1962.
22. Wong CF, McCarthy M, Howse ML, Williams PS. Factors
affecting survival in advanced chronic kidney disease patients who
choose not to receive dialysis. Ren Fail. 2007;29(6):653-659.
23. Kelley AS, Meier DE. Palliative care—a shifting paradigm.
N Engl J Med. 2010;363(8):781-782.
24. Connor SR, Pyenson B, Fitch K, Spence C, Iwasaki K.
Comparing hospice and nonhospice patient survival among pa-
tients who die within a three-year window. J Pain Symptom
Manage. 2007;33(3):238-246.
25. Rabow MW, Dibble SL, Pantilat SZ, McPhee SJ. The
comprehensive care team: a controlled trial of outpatient palliative
medicine consultation. Arch Intern Med. 2004;164(1):83-91.
26. Smith TJ, Cassel JB. Cost and non-clinical outcomes of
palliative care. J Pain Symptom Manage. 2009;38(1):32-44.
27. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings
associated with US hospital palliative care consultation programs.
Arch Intern Med. 2008;168(16):1783-1790.
28. Davison SN. End-of-life care preferences and needs: percep-
tions of patients with chronic kidney disease. Clin J Am Soc
Nephrol. 2010;5(2):195-204.
29. Fine A, Fontaine B, Kraushar MM, Rich BR. Nephrologists
should voluntarily divulge survival data to potential dialysis pa-
tients: a questionnaire study. Perit Dial Int. 2005;25(3):269-273.
30. Davison SN, Simpson C. Hope and advance care planning
in patients with end stage renal disease: qualitative interview
study. BMJ. 2006;333(7574):886.
31. Thong MS, Kaptein AA, Benyamini Y, Krediet RT, Boescho-
ten EW, Dekker FW. Association between a self-rated health
question and mortality in young and old dialysis patients: a cohort
study. Am J Kidney Dis. 2008;52(1):111-117.
32. Moss AH, Ganjoo J, Sharma S, et al. Utility of the “sur-
prise” question to identify dialysis patients with high mortality.
Clin J Am Soc Nephrol. 2008;3(5):1379-1384.
33. Cohen LM, Ruthazer R, Moss AH, Germain MJ. Predicting
six-month mortality for patients who are on maintenance hemodi-
alysis. Clin J Am Soc Nephrol. 2010;5(1):72-79.
34. Cohen LM, Ruthazer R, Germain MJ. Increasing hospice
services for elderly patients maintained with hemodialysis. J
Palliat Med. 2010;13(7):847-854.
35. Renal Physician Association. Shared Decision-Making in
the Appropriate Initiation and Withdrawal From Dialysis Clinical
Practice Guidelines. 2nd ed. Rockville, MD: RPA, 2010.
36. Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes
BJ, Tolle SW. A comparison of methods to communicate treatment
preferences in nursing facilities: traditional practices versus the
physician orders for life-sustaining treatment program. J Am Geri-
atr Soc. 2010;58(7):1241-1248.
37. Citko J, Moss A, Carley M, Tolle S. The National POLST
Paradigm Initiative, 2nd ed. Fast Fact and Concepts. September
2010;178. http://www.eperc.mcw.edu/fastfact/ff_178.htm. Ac-
cessed December 1, 2010.
Am J Kidney Dis. 2011;57(3):378-380