Patients with End-Stage Renal Disease and Acute Surgical Abdomen: Opportunities for Palliative Care

Referral Criteria to Specialist Palliative Care for People with Advanced Chronic Kidney Disease: A Systematic Review

CONTEXT

People with advanced chronic kidney disease (CKD) have significant morbidity, yet for many, access to palliative care occurs late, if at all.

OBJECTIVES

This study sought to examine criteria for referral to specialist palliative care for adults with advanced CKD with a view to improving use of these essential services.

METHODS

Systematic review of studies detailing referral criteria to palliative care in advanced CKD conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guideline and registered (PROSPERO: CRD42021230751).

DATA SOURCES

Electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed) were used to identify potential studies, which were subjected to double review, data extraction, thematic coding, and descriptive analyses.

RESULTS

Searches yielded 650 unique titles ultimately resulting in 56 studies addressing referral criteria to specialist palliative care in advanced CKD. Of 10 categories of referral criteria, most commonly discussed were: Critical times of treatment decision making (n = 23, 41%); physical or emotional symptoms (n = 22, 39%); limited prognosis (n = 18, 32%); patient age and comorbidities (n = 18, 32%); category of CKD/ biochemical criteria (n = 13, 23%); functional decline (n = 13, 23); psychosocial needs (n = 9, 16%); future care planning (n = 9, 16%); anticipated decline in illness course (n = 8, 14%); and hospital use (n = 8, 14%).

CONCLUSION

Clinicians consider referral to specialist palliative care for a wide range of reasons, with many related to care needs. As palliative care continues to integrate with nephrology, our findings represent a key step towards developing consensus criteria to standardize referral for patients with chronic kidney diseases.

The effect of comorbidity on early clinical decision making in acute mesenteric ischemia

INTRODUCTION

Acute mesenteric ischemia (AMI) is a surgical emergency with a high mortality and morbidity rate. Prompt diagnosis and early surgical management are the cornerstones of management. In certain patients, however, treatment is futile and early palliative care, lessens patient, and family distress. The aim of this study was to investigate factors, focusing on patient comorbidity, that may predict futility of treatment and hence, guide clinicians in their decision making.

PATIENTS AND METHODS

Consecutive adult patients with AMI diagnosed on imaging were reviewed for demographics, comorbidity, imaging, and biochemical results.

RESULTS

Seventy patients were identified with average age of 67 (range 33 - 94). Overall hospital mortality was 72%. Patients were divided into three distinct groups, patients who recovered (27%), patients deceased despite surgical treatment (18%), and patients palliated on presentation (54%). Age was comparable between groups (61 vs. 69 vs. 69; p=.2). Length of stay was highest in the recovered group (41.6 vs. 12.3 vs. 2.8 d). Biochemically, only lactate level differed (3.1 vs. 2.3 vs. 5.3 mmol/L, p=.03). Both deceased and palliative group scored similarly but significantly higher than the recovered group in both the Charlson comorbidity index (CCI) (4.2 and 5.6 vs. 3.4, p=.02) and age-adjusted CCI (ACCI) (6.7 and 8.2 vs. 5; p<.01). Other co-morbidities of atrial fibrillation (AF) and hypertension were comparable.

CONCLUSIONS

Raised ACCI confers poor outcomes in AMI despite surgical management. ACCI may be used to aid early decision making in AMI, predicting futility of treatment, and altering management goals to palliative comfort care.