1. Conservative Renal Management
Jacqui Nevols
December 2015

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

3. Survival on RRT

4. 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

5. 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

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

7. 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

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

9. 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

10. 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

11. 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!

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

14. 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