Experience of a renal palliative care program in a Hong Kong center: Characteristics of patients who prefer palliative care to dialysis

Abstract

Background: A renal palliative care (RPC) program was developed in a local center as an option for patients with end-stage renal disease (ESRD) who may not benefit from dialysis or who do not prefer dialysis. The model involved collaboration between the palliative care and renal teams, and the RPC program was introduced as an option in the advance care planning (ACP) interview during which treatment benefits, burdens, predicted prognosis and the patient's preferences were discussed. Patients who preferred palliative care to dialysis were recruited into the RPC program. An interdisciplinary team approach was adopted and the Renal Palliative Clinic comprised the core component among the full spectrum of services. Methods: This was a retrospective study of the characteristics of ESRD patients who were interviewed for ACP between August 2007 and the end of 2008 and who preferred palliative care to dialysis. Results: A total of 96 ESRD patients were interviewed for ACP during this period, among which 36 patients opted for dialysis while 60 patients chose RPC. In both groups, around 97% of patients were mentally competent and involved in ACP. The patients who chose RPC, as compared with the patients who opted for dialysis, were older (74.1±8.7 years vs. 56.3±10.0 years, p<0.001), included more widowers (40.0% vs. 2.8%, p<0.001), were more financially dependent on their family (65.0% vs. 36.1%, p<0.001), had a higher incidence of diabetes mellitus (73.4% vs. 41.6%, p=0.002), and had a higher modified Charlson Comorbidity Index (9.5±1.9 vs. 6.9±3.1, p<0.001). More RPC patients relied on assistance to walk and had a constant caregiver at home. The decision for RPC was primarily the patient's in 41.7%, while it was a shared family decision in 56.5%. The reasons given for declining dialysis were perceived undue physical burden in 60.1%, social burden in 53.4%, and psychological burden in 56.8%, while 35.1% of patients cited all of the above reasons for their decision. By the end of 2008, 30 (50.0%) RPC patients had died, after receiving palliative care for a median duration of 132.5 days (range, 3-437 days; interquartile range, 115.0). They all lived with their choice of RPC until death. Conclusion: The RPC program, introduced as an option in ACP, was appropriate in meeting the preferences and needs of a significant proportion of ESRD patients and their families.