End of Life Care in End Stage Kidney Disease
Ethical and compassionate care is the main goal when managing a patient at the end of life. This period can be defined as a “ period of irreversible functional decline prior to death ” [49] . Care plans need to be adjusted to allow patients to have a “good death”, where distressing symptoms and suffering are treated competently and compassionately. The ethical framework that underpins endof-life
Ethical and compassionate care is the main goal when managing a patient at the end of life. This period can be defined as a “period of irreversible functional decline prior to death” [49]. Care plans need to be adjusted to allow patients to have a “good death”, where distressing symptoms and suffering are treated competently and compassionately. The ethical framework that underpins endof-life care [49] includes:
- Maintain open communication with the patient and the family
- Provide adequate relief of pain and other symptoms
- Ensure continuity of care of the patient
- Do not subject a dying patient to futile treatment that can increase distress
- Provide integrated bio-psychosocial and spiritual care
- Families should be actively supported during this time and during their bereavement.
Common signs and symptoms of a dying patient [49]:
- Weight loss
- Profound weakness and fatigue
- Social withdrawal
- Not eating
- Delirium, confusion or drowsiness
- Difficulty in swallowing
- Severe dyspnoea
- Decreased or no urine output
- Anasarca
- Cool skin.
Essential care steps:
- All members of the care team should communicate effectively with one another so that the advanced care plan, should there be one, is respected and instituted.
- All members of the care team should be adept at communicating compassionately with the patient and the family in order to break bad news and initiate discussions around withdrawing or withholding artificial nutrition, inappropriate hydration and medically inappropriate investigations or interventions.
- The patient’s decision regarding place of death should be respected as far as possible.
- Medication management:
- Rationalise medications: stop those not contributing to improvement in quality of life.
- Prescribe medication to treat symptoms and anticipated problems.
- Use an effective route, especially if the patient cannot swallow, e.g. subcutaneous, intravenous or intramuscular.
- Nursing care should be focused on dignity and avoiding unnecessary nursing interventions.
- Family care:
- Families need to be compassionately informed about the prognosis and should be provided with information around the expected symptoms and management. Healthcare providers should be led by the families around the type and amount of information provided.
- Children need to be appropriately addressed with suitable referrals being made where necessary.
- Prepare the patient’s family and carers regarding bereavement, building resilience and practical aspects of handling the deceased’s body and dealing with undertakers – all of which should be respectful of the patient’s cultural and religious preferences.
- Spiritual care should be offered and provided to all patients and families.
- Support for healthcare professionals involved in caring for the deceased should be provided and include debriefing and building resilience.
- Auditing and reflection of this process would allow improvement in the managing of the dying patient with ESKD.
Wearne, N., Krause, R., Davidson, B., and Brennan, F., 2020. Renal palliative and supportive care in South Africa – A consensus statement. African Journal of Nephrology, 23(1), pp.86-107.