Conservative Renal Management Jacqui Nevols December 2015

Outline of talk Choosing not to dialyse Conservative Care Aims Symptom control Planning for the Future Withdrawal of dialysis Palliative Care

Survival on RRT

Choosing not to dialyse Predictors of poor outcome Dementia Severe peripheral vascular disease Hypotensive heart failure Severe mental illness Malignant disease with poor prognosis Some patients do much better than predicted

Dialysis for the frail elderly patient Length of life may not improve on RRT Quality of life may worsen on dialysis High incidence of complications e.g. sepsis Repeated hospital admissions/time away from home Repeated interventions ↑Likelihood of dying in hospital Transport to and from dialysis Recovery/dialysis hangover

Decision making Can’t be rushed Family involvement Documentation Difficult if uraemic ???Trial of dialysis Patients can, and do, change their mind

Aims of Conservative Care Protect and maintain renal function Prevent and treat symptoms Improve quality of life Plan for the future Avoid hospital admissions Psychological, social, financial and spiritual support Continued renal team input

Symptom Control DEPRESSION AND ANXIETY Anaemia – lethargy Nausea Shortness of breath Pain Restless legs Itch Mouth care Appetite/taste problems DEPRESSION AND ANXIETY

Death in renal patients Sudden End of life phase (may be poorly recognised) Dialysis withdrawal Conservative care Cardiac arrest on dialysis Few have a DNAR discussion 3% survive to 6 months (<10% to hospital discharge) Distressing to staff and other patients

Withdrawal of Dialysis Stopping dialysis is NOT euthanasia Patient is allowed to die naturally Capacity to make decision? Patient may feel they are letting others down Decision may be initiated by patient or staff e.g. after a major stroke

Death in renal patients Inevitable Patients should be able to die: Peacefully With dignity Symptom free In a place of their choosing surrounded by loved ones Requires Planning!

Checklist Will Living will DNAR documentation Power of Attorney Affairs in order – inventory Statement of wishes (?funeral, ?cremation ? tissue donation) Letters to loved ones

Conclusion Focus care on comfort, rather than the prolongation of life Discussions about death are avoided by patients, their families and clinicians Dialysis may impair quality of life Guidelines for symptom control in preparation – watch this space ESRD cannot be cured – teach patient how to cope and maximise health and well being