Renal Palliative care
30.00
54.40
78.90
99.40
114.80
234.40 236.40
275.30
302.60
419.95
507.50
0
100
200
300
400
500
600
1 2 3 4 5 6 7 8 9 10 11...
Chapter 1: History of Thai RRT Registry
Chapter 2: Provision of Dialysis in Thailand
in Year 2007
Chapter 3: Economics of ...
2007: Cases (pmp) 2008: Cases (pmp)
•Hemodialysis 20,641 (327.4) 25,372 (402.5)
•Peritoneal Dialysis 1,198 (19.0) 2,415 (3...
2007 2008
Population
( Millions)
Cases
( pmp)
Population
( Millions)
Cases
( pmp)
CSMBS 7 8,956 (1279.4) 7 11,272 (1610.4)...
Prevalence of Peritoneal Dialysis Cases: 2007-2008
2007 2008
Populatio
n
( Millions)
Cases
( pmp)
Population
( Millions)
C...
Etiology of ESRD in Incident RRT Cases 2007-2008
Case per Millions
Hemodialysis 1113.07
Peritoneal Dialysis 88.46
Total 1201.83
จำำนวนประชำกรอำยุ 60 ปี ขึ้นไป
พ.ศ.2546 6.6...
29.9
21.6
9.6 9.8
6.9
5.3
0
5
10
15
20
25
30
35
45-54 55-64
Healthy
Colon CA
ESRD
Expected Remaining Lifetime
(Years)
Age ...
• 65 years old man, DM, Hypertension, Dyslipidemia
Chronic HD X 5 years
IHD post-CABG, recurrent ischemic stroke, PVD
Bed ...
• 85 years old man, chronic lung disease, Hypertension, on
home oxygen therapy, parkinson’s disease
IHD post-CABG, recurre...
SUFFERING
EMOTIONALPSYCHOSOCIAL
PHYSICAL
SPIRITUAL
PALLIATIVE CARE:
World Health Organization Definition
Palliative care is an approach that improves the
quality of life of ...
Cure/Life-prolongingCure/Life-prolonging
IntentIntent
Palliative/Palliative/
Comfort IntentComfort Intent
Bereavement
Bere...
Palliative care programs :
• Traditionally focused on supporting people with
cancer
• Life-limiting chronic illness
• Focu...
• Where does RRT fit in Palliative Care?
• Where does Palliative Care fit in RRT?
RRT vs Palliative Care
• 65 years old man, DM, Hypertension, Dyslipidemia
Chronic HD X 5 years
IHD post-CABG, recurrent ischemic stroke, PVD
Bed ...
Advance Care Planning is the process of dialogue,
knowledge sharing, and informed decision-making that
needs to occur at a...
This is often referred to as palliative or comfort care. It
focuses on aggressive relief of pain and discomfort. There is
...
This provides palliative and comfort care, but also allows for
treatment of reversible conditions (e.g. pneumonia, blood
c...
This provides any necessary palliative and comfort care as
above, plus available treatment of all conditions, both
reversi...
This plan provides for all available treatment
of all conditions, and includes full CPR.
Advance Care Plan 4
Withdrawal of Dialysis
Catalano C et al, Nephrol Dial Transplant. 1996 Jan;11(1):133-9.
0
10
20
30
40
50
60
< 3 3 - 10 > 1...
Nephrol Dial Transplant 2005: 20; 392-395
• 85 years old man, chronic lung disease, Hypertension, on
home oxygen therapy, parkinson’s disease
IHD post-CABG, recurre...
Palliative Care Issues communication in
Ensuring Comfort
– Anorexia
– Nausea
– Constipation
– Pain, neuropathy
– Cramp, re...
Fluid overload
Avoiding salt and salty foods and reducing
fluid intake may be enough to prevent serious
problems with flui...
Pruritus
• Common in ESRD; prevalence 50 – 90 %
• Exclusion of other causes of pruritus, including systemic or
dermatologi...
Terminal phase care
•
A patient with deteriorating kidney function who chooses not to
have dialysis has an average surviva...
Lack of dedicated renal palliative care service
Lack of renal palliative care teaching and training
Lack of advance care p...
Early Detection of CRF
Prevention of
uremic
complications
Interventions
that delay
progression
Modification
of
comorbidity...
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  1. 1. Renal Palliative care
  2. 2. 30.00 54.40 78.90 99.40 114.80 234.40 236.40 275.30 302.60 419.95 507.50 0 100 200 300 400 500 600 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 CasesperMillionPopulation Year1997 1998 1999 2000 2001 2003 2004 2005 2006 2007 2008 Annual Prevalence Trend (1997 – 2008) Year
  3. 3. Chapter 1: History of Thai RRT Registry Chapter 2: Provision of Dialysis in Thailand in Year 2007 Chapter 3: Economics of Dialysis in Thailand in Year 2007 Chapter 4: Etiology of ESRD Chapter 5: RRT Center Chapter 6: Human Resources of RRT Chapter 7: Dialysis Practice Chapter 8: Vascular Access Chapter 9: Renal Anemia Management Chapter 10: Renal Bone Disease Management Chapter 11: Adequacy of Hemodialysis Chapter 12: Metabolic Acidosis and Hyperkalemia Chapter 13: RRT in Pedriatrics
  4. 4. 2007: Cases (pmp) 2008: Cases (pmp) •Hemodialysis 20,641 (327.4) 25,372 (402.5) •Peritoneal Dialysis 1,198 (19.0) 2,415 (38.3) •Kidney Transplant 3618 (57.4) 4,202 (66.6) Total 26,457 (419.9) 31,989 (507.5) The prevalence of RRT patients in year 2007- 2008
  5. 5. 2007 2008 Population ( Millions) Cases ( pmp) Population ( Millions) Cases ( pmp) CSMBS 7 8,956 (1279.4) 7 11,272 (1610.4) SSS 8 3279 (409.8) 8 4,270 (533.8) Self payment 48 8405 (175.1) 48 9,828 (204.7) Total 63 20641 (327.4) 63 25372 ( 402.5) Prevalence of Hemodialysis Cases: 2007-2008
  6. 6. Prevalence of Peritoneal Dialysis Cases: 2007-2008 2007 2008 Populatio n ( Millions) Cases ( pmp) Population ( Millions) Cases ( pmp) CSMBS 7 971 (138.7) 7 854 (122.0) SSS 8 60 (7.6) 8 78 (9.7) Self payment 48 165 (3.4) 48 1,482 (30.8) Total 63 1198 (19.0) 63 2415(38.3)
  7. 7. Etiology of ESRD in Incident RRT Cases 2007-2008
  8. 8. Case per Millions Hemodialysis 1113.07 Peritoneal Dialysis 88.46 Total 1201.83 จำำนวนประชำกรอำยุ 60 ปี ขึ้นไป พ.ศ.2546 6.6 ล้ำนคน พ.ศ.2551 7.8 ล้ำนคน
  9. 9. 29.9 21.6 9.6 9.8 6.9 5.3 0 5 10 15 20 25 30 35 45-54 55-64 Healthy Colon CA ESRD Expected Remaining Lifetime (Years) Age Group US Renal Data System
  10. 10. • 65 years old man, DM, Hypertension, Dyslipidemia Chronic HD X 5 years IHD post-CABG, recurrent ischemic stroke, PVD Bed ridden X 2 years, NG tube feeding, recurrent UTI/urosepsis, recurrent CHF/volume overload, intradialystic hypotension, vascular calcification, soft tissue infection related to calciphylaxis, multiple admission related to HD complications, progressive decrease sensorium, depression
  11. 11. • 85 years old man, chronic lung disease, Hypertension, on home oxygen therapy, parkinson’s disease IHD post-CABG, recurrent CHF/volume overload, intractable CHF BUN 70 mg%, Cr 6.8 mg%
  12. 12. SUFFERING EMOTIONALPSYCHOSOCIAL PHYSICAL SPIRITUAL
  13. 13. PALLIATIVE CARE: World Health Organization Definition Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
  14. 14. Cure/Life-prolongingCure/Life-prolonging IntentIntent Palliative/Palliative/ Comfort IntentComfort Intent Bereavement Bereavement D E A T H “Active Treatment” PalliativePalliative CareCare D E A T H EVOLVING MODEL OF PALLIATIVE CARE
  15. 15. Palliative care programs : • Traditionally focused on supporting people with cancer • Life-limiting chronic illness • Focuses on the need to expand palliative care services for people with CKD. 50% of patients over the age of 80 had died within 12 months of starting dialysis
  16. 16. • Where does RRT fit in Palliative Care? • Where does Palliative Care fit in RRT? RRT vs Palliative Care
  17. 17. • 65 years old man, DM, Hypertension, Dyslipidemia Chronic HD X 5 years IHD post-CABG, recurrent ischemic stroke, PVD Bed ridden X 2 years, NG tube feeding, recurrent UTI/urosepsis, recurrent CHF/volume overload, intradialystic hypotension, vascular calcification, soft tissue infection related to calciphylaxis, multiple admission related to HD complications, progressive decrease sensorium, depression
  18. 18. Advance Care Planning is the process of dialogue, knowledge sharing, and informed decision-making that needs to occur at any time when future or potential end-of-life treatment options and preferences are being considered or revisited. The primary goal of Advance Care Planning is to seek consensus on care plans that reflect the best interests of clients/patients/residents. Advance Care Planning
  19. 19. This is often referred to as palliative or comfort care. It focuses on aggressive relief of pain and discomfort. There is no CPR (intubation, assisted ventilation, defibrillation, chest compressions, advanced life support medications). There are also no life sustaining or curative treatments such as ICU, tube feeds, transfusions, dialysis, IV’s, and certain medications. All available tests and treatments necessary for palliation are done, including medications and transfer to hospital if necessary. Advance Care Plan 1
  20. 20. This provides palliative and comfort care, but also allows for treatment of reversible conditions (e.g. pneumonia, blood clot) that may have developed. There is no CPR. ICU, all available tests, and treatments for reversible conditions are offered, based on medical assessment, except for CPR. Certain tests and treatments for any reversible conditions may be refused based on your values (e.g., tube feeds, dialysis, ICU, transfusions, IV’s, certain medications, certain tests, transfer to hospital, etc.) Advance Care Plan 2
  21. 21. This provides any necessary palliative and comfort care as above, plus available treatment of all conditions, both reversible and nonreversible, with no restrictions, except for CPR. There is no CPR. As above, a person may elect to refuse any tests or treatments for both nonreversible and reversible conditions. If so, they should be listed: Advance Care Plan 3
  22. 22. This plan provides for all available treatment of all conditions, and includes full CPR. Advance Care Plan 4
  23. 23. Withdrawal of Dialysis Catalano C et al, Nephrol Dial Transplant. 1996 Jan;11(1):133-9. 0 10 20 30 40 50 60 < 3 3 - 10 > 10 Survival Time Following Discontinuation of Dialysis (Days) #Patients n = 88 Median survival = 8 days
  24. 24. Nephrol Dial Transplant 2005: 20; 392-395
  25. 25. • 85 years old man, chronic lung disease, Hypertension, on home oxygen therapy, parkinson’s disease IHD post-CABG, recurrent CHF/volume overload, intractable CHF BUN 70 mg%, Cr 6.8 mg%
  26. 26. Palliative Care Issues communication in Ensuring Comfort – Anorexia – Nausea – Constipation – Pain, neuropathy – Cramp, restless leg syndrome, myoclonus, twitching – Confusion, lethargy – Dyspnea – fluid balance, pneumonia – Pruritus
  27. 27. Fluid overload Avoiding salt and salty foods and reducing fluid intake may be enough to prevent serious problems with fluid overload. Diuretics such as furosemide up to 250- 500mg/day and metolazone 2.5mg daily can be used. Sometimes patients may require hospital admission for IV diuretics.
  28. 28. Pruritus • Common in ESRD; prevalence 50 – 90 % • Exclusion of other causes of pruritus, including systemic or dermatological causes; • Correction of biochemical imbalances such as high calcium, or parathyroid levels; • Identification of xerosis (dry skin) and the use of liberal emollients; • If pruritus is widespread, terfenadine may be used; • For widespread itch that disrupts sleep more sedating antihistamines such as chlorphenamine may be used; • Another medication (to be used with caution) is ondansetron. • While pruritus remains difficult to treat, it can have a significant impact on patients’ quality of life.
  29. 29. Terminal phase care • A patient with deteriorating kidney function who chooses not to have dialysis has an average survival time of 6.3 months. • In those who withdraw from dialysis, the average time to death is eight days. • Detailed and skilled palliative care planning in the terminal phase of CKD is paramount.
  30. 30. Lack of dedicated renal palliative care service Lack of renal palliative care teaching and training Lack of advance care planning Lack of identifying the ESRD subgroup suitable for renal palliative care TALKING ABOUT DYING
  31. 31. Early Detection of CRF Prevention of uremic complications Interventions that delay progression Modification of comorbidity Preparation for RRT ACE inhibitors BP control Metabolic acidosis Blood sugar control Rx of hypo K, hyper P., hyperlipidemia Protein restriction Malnutrition Anemia Osteodystrophy Acidosis Cardiac disease Vascular disease Neuropathy (in diabetics) Retinopathy (in diabetics) Education Informed choice of RRT Timely access placement Timely initiation of dialysis Optimum Pre-ESRD care
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