title: End-of-life matters in chronic renal failure.
abstract: OBJECTIVE
  The population considered eligible for dialysis has expanded dramatically over the past 4 decades, so that a significant proportion of patients receiving renal replacement therapy are elderly, frail and infirm. These patients have an extremely limited life expectancy and suffer from significant symptom burden, similar to patients with other end-stage organ failure or cancer. As dialysis has been offered more broadly, it is now initiated earlier than in decades past, further adding to cost and patient burden.
  
  
  RESULTS
  The trend toward more expansive and intensive care has not been corroborated by robust data. In response, an increasing number of studies has focused on establishing reasonable limits to renal replacement therapy. Multiple authors have explored the role of conservative kidney management for high-risk dialysis patients as an alternative to dialysis, which may offer similar survival and improved quality of life in certain populations. For those who chose dialysis, deferring initiation until the patient becomes symptomatic may be a reasonable. Evidence-based symptom management guidelines for dialysis patients remain largely absent, with few proven approaches. Hospice and palliative care resources remain underutilized.
  
  
  CONCLUSIONS
  For a subset of dialysis patients, palliative care and conservative kidney management are appropriate and underutilized.
  http://links.lww.com/COSPC/A8
authors.affiliation: aWeill Cornell Medical College bRogosin Institute, New York, New York, USA.
authors.forename: Nathaniel
authors.initials: N
authors.lastname: Berman
mesh_terms: D017281:Cost of Illness; D006801:Humans; D007676:Kidney Failure, Chronic / Q000191:economics / Q000628:therapy*; D010166:Palliative Care / Q000379:methods*; D018802:Patient-Centered Care; D011788:Quality of Life; D017582:Renal Replacement Therapy / Q000191:economics / Q000706:statistics & numerical data*; D013727:Terminal Care / Q000379:methods*; D013997:Time Factors