ANZSN Renal Supportive Care Guidelines 2013

• Nephrologists seek to provide dialysis to those who will benefit most while being honest and direct with those who are unlikely to benefit or even be harmed by dialysis; these can be difficult decisions. • A ‘conservative’ or ‘not for dialysis’ pathway is an important option for the management of end-stage kidney disease (ESKD) patients who are elderly, have significant comorbidity, poor functional status, malnutrition or who reside in a nursing home. • Such a pathway is best underpinned by a specific renal supportive care programme in each unit. • Nephrologists need to lead realistic discussions about likely survival with patients and their families before dialysis is instituted. • Key ethics principles are a good aid in this decision-making process • A ‘non-dialysis’ renal supportive care programme is a very positive way of offering holistic care for patients and their families; many of these patients live much longer without dialysis than might have been expected. Perhaps the most difficult decision facing nephrologists today is that of ‘selecting’ which patients will benefit from dialysis in an overall person-centred sense, not just in terms of days survived or achievement of target haemoglobin, Phosphate, Kt/V or other outcomes. The overall aim is to help and direct patients and their families so as to encourage those who will benefit most from dialysis to have this while being honest and direct with those who are unlikely to benefit or even be harmed by dialysis. Consequently it is imperative that we have mechanisms in place that support those who do not receive dialysis in such a way that they have good symptom control and quality of life (QOL). While the discussions below apply to every potential dialysis patient regardless of age, in practice most ‘younger’ patients (below 70) are likely to be offered dialysis; these considerations below become far more relevant for discussions with patients who are over 70 years old with stage 4 or 5 end-stage kidney disease (ESKD). We are therefore looking at three potential pathways for patients with ESKD: 1 Not for dialysis or transplantation – a clear decision based on medicalandethicalgroundsincorporatingthepatient’swishes. 2 For dialysis or transplantation. 3 Indeterminate – that group for whom the treating nephrologist and the patient are unable to come to a clear decision. For people in this group, seeking a second opinion and ideally, discussing the case at a multidisciplinary team meeting (similar to those discussions surrounding acceptance onto the transplant waiting list) are paths to follow. A very important principle is that these planning discussions need to take place early in the course of a patient’s management, probably when estimated Glomerular Filtration Rate (eGFR) reaches 25 mL/min. There are some key principles that can help nephrologists, patients and their families make these decisions: 1 Nephrologists need to lead these discussions – these are very difficult discussions but it is imperative that as nephrologists we do not shy away from them as this is to the ultimate detriment of the patient and their family. In some centres it may be that nephrologists do not see the same patients regularly and the temptation here will be either to use dialysis as the default choice for all patients or else to leave these discussions to other medical or nursing staff. It is inappropriate for these discussions to be delegated to more junior medical staff but advanced trainees and Junior Medical Officers (JMOs) should be present as part of their training. Initial discussions are generally best if done with the nephrologist and his/her medical team, and then followed by more detailed discussions with nursing staff and allied health staff. Ideally a renal supportive care (RSC) programme team will help facilitate these ongoing discussions with a patient and their family when a conservative not-for-dialysis pathway is chosen and a pre-dialysis team will assist those for whom dialysis is considered the correct management pathway. Many nephrologists have already made it part of their usual practice to offer a ‘non-dialysis’ pathway to selected patients but many are also understandably troubled when making such decisions. This issue has become more prominent because of the increasing number of aged patients with comorbidities, frailty, or poor functional status who present with end stage kidney disease, for whom decisions need be made as to the appropriateness of dialysis. 2 Nephrologists need to have realistic discussions about likely patient survival on dialysis – data are available from Australian and New Zealand Dialysis and Transplant Association (ANZDATA) to guide this. We need to be aware that these discussions are likely to be aimed at frail, ‘marginal’ patients of any age although most of the available data deal specifically with those over the age of 75 years: a. Current data show that patients starting dialysis in the 75–84 years age group, presumably already selected to some extent by their nephrologists as suitable bs_bs_banner