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 often 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.


OBJECTIVE
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.


METHODS
A retrospective audit of deceased patients' charts, spanning three years, and a survey of renal healthcare professionals, documenting CKD palliative care practices, knowledge and attitudes was carried out. Records of all patients with CKD dying between 1 January 2006 and 31 December 2008 in Australian regional renal service were audited. Renal staff from the service were surveyed. 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 was undertaken.


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. Whilst renal healthcare professionals support early discussion of end-of-life care at predialysis 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 predialysis education to enable clearer decision making.
School of Nursing and Midwifery, University of Tasmania, Launceston, Tasmania, Australia.
Rosalind
R
Bull
Loren
L
Youl
Iain K
IK
Robertson
Rose
R
Mace
Sarah
S
Challenor
Robert G
RG
Fassett
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D001315:Australia; D003657:Decision Making; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D016015:Logistic Models; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods*; D051436:Renal Insufficiency, Chronic / Q000628:therapy*; D012189:Retrospective Studies; D013727:Terminal Care / Q000379:methods*
Chronic kidney disease; Palliative care; Withdrawal