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INTRODUCTION

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Palliative care is an approach to patient care in which there is a focus on improving the quality of life of patients and families living with complex or life limiting illnesses by ensuring that treatment is consistent with patient goals and values, as well as prompt identification and aggressive treatment of symptoms. It is often inappropriately interchanged with hospice or end of life care, though this is only a small portion of palliative care. Unlike hospice care, which is offered in the last 6 months of life, palliative care can be incorporated early, at any stage of a serious or life limiting illness and can be offered concurrently with curative or disease specific therapies (Figure 58–1). Though use has been well established in cancer and congestive heart disease, recognition of the needs in patients with chronic kidney disease (CKD) has led to a growing interest in this field of palliative care nephrology. CKD is a life-limiting condition that will necessitate the need for patients, family members, and care providers to engage in discussions regarding treatment decisions. As the number of patients with CKD increases, and as incident dialysis patients are ageing, the demand for palliative care will soon overwhelm the current availability of specialty trained physicians. There are several important palliative care skills that specialty providers should be sufficient in, in order to streamline care. These skills include the ability to engage in shared decision making including prognostication of patients with CKD and discussions regarding modality selection including conservative therapy, symptom identification and basic management, and laying the foundation for advanced care planning. Integration of nephrology and palliative care exists in certain areas of the world in which conservative care, or supportive care clinics are well established for caring for patients with CKD, some of who may opt for nondialysis, or conservative treatment of their advanced kidney disease. Referral to, or consultation with palliative care physicians is appropriate if the aforementioned needs are unable to be met by the nephrology provider, for the complicated patient or family dynamic, or for assistance with discussions and transitions for end of life care including hospice.

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Figure 58–1.

Updated palliative care model: palliative care can be incorporated early, at any stage of a serious or life-limiting illness and can be offered concurrently with curative or disease specific therapies. Hospice is a subset of palliative care that is focused upon patients who have a prognosis of 6 months or less. (Adapted from Lynn J, Adamson DM: Living Well at the End of Life: Adapting Health Care to Serious Chronic Illness in Old Age. Santa Monica, CA: RAND Health, 2003. http://www.rand.org/pubs/white_papers/WP137.html.)

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SHARED DECISION MAKING

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The Renal Physicians Association (RPA) highlights shared decision making as the preferred approach to patient centered care when discussing treatment options for advanced renal disease. It is a ...

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