Pathways to palliative care for patients with Chronic Kidney Disease

Background: Despite the terminal nature of Chronic kidney disease (CKD), end-of-life care planning is inconsistent and pathways to palliative care are unclear. Health professionals’ perceptions of palliative care and the prevailing context may influence their end-of-life decision-making.

Objectives: to identify predictors of conservative treatment decisions and their associations with referral to palliative care, and to determine the perceptions that health professionals have about the role of palliative care in management of CKD.

Design: A retrospective deceased patient chart audit spanning three-years and a survey of renal healthcare professionals, documenting CKD palliative care practices, knowledge and attitudes.

Participants: Records of all CKD patients dying between 1 Jan 2006 and 31 Dec 2008 in Australian regional renal service were audited. Renal staff from the service were surveyed.

Measurements: Logistic regression for binomial outcomes and ordinal logistic regression when more than two outcome levels were involved; and thematic analysis using a continual cross comparative approach.

Results: Loss of function, particularly from stroke, and severe pain are interpreted as representing levels of suffering which would justify the need to withdraw from renal replacement therapy. Family and/or patient indecision complicates and disrupts end-of-life care planning and can establish a cycle of ambiguity. While renal healthcare professionals support early discussion of end-of-life care at pre-dialysis education, congruity with the patient and family when making the final decision is of great importance.

Conclusions: Healthcare professionals’ beliefs, values and knowledge of palliative care influence their end-of-life care decisions. The influence of patient, family and clinicians involves negotiation and equivocation. Health professionals support the early discussion of end-of-life-care in CKD at pre-dialysis education to enable clearer decision-making.