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Abstract: PO1380

Dialysis for the Hospice Patient: A Paradoxical Challenge for Palliative Nephrology

Session Information

Category: Geriatric Nephrology

  • 1100 Geriatric Nephrology

Authors

  • Portugal, Frank A., Rutgers Robert Wood Johnson Medical School New Brunswick, New Brunswick, New Jersey, United States
  • Khalil, Steve I., Rutgers Robert Wood Johnson Medical School New Brunswick, New Brunswick, New Jersey, United States
Introduction

We present a case of a patient who developed anuric AKI who subsequently needed dialysis while patient and family were also simultaneously interested in hospice. Our case addresses the difficult conversation in prognosticating and how hospice eligibility for patients requiring dialysis can be challenging.

Case Description

A 63-year-old woman with hypertension and recently diagnosed metastatic pancreatic adenocarcinoma initially presented for intractable right hip pain and was admitted for emergent palliative radiation. She experienced rapid deterioration including septic and hemorrhagic shock and was managed in the ICU until she was later stabilized off pressors and downgraded to the floors. Unfortunately, she had further complications and quickly experienced anuric AKI from ischemic ATN as her serum creatinine rose from 0.8 to 4.9 mg/dL and became significantly volume overloaded with worsening acidemia. The decision was to start a trial of dialysis by family, but they also wanted hospice. Questions arose including prognosis and if patient could simultaneous be provided with dialysis during hospice. Given the current model of withdrawing from dialysis for hospice eligibility, the daughters agreed to transition their mother to hospice. The patient passed prior to leaving the hospital.

Discussion

We present a difficult scenario for the nephrologist as serious illness conversations remain incredibly challenging. We may opt to not take part in these conversations either due to time commitment, not viewing it as a primary responsibility, or not wishing to upset the patient and their families. Also, so much uncertainty in predicting prognosis makes it intimidating. Here, what also needed to be addressed were hospice benefits for the dialysis patient, if any existed. Usually, one is required to withdraw from dialysis to receive hospice care. There have been suggestions in providing a trial or “as needed dialysis” to focus on a patient-centered type of care but unfortunately that could potentially impact quality metrics and Medicare reimbursement for dialysis centers. As such, these ongoing challenges not only require collaboration between Nephrology and Palliative medicine but also changes at the national broader level.