Physical Therapy in Palliative Care From Symptom Control to Quality of Life a Critical Review
Cease-Stage Renal Disease: Symptom Direction and Advance Care Planning
Am Fam Physician. 2012 Apr 1;85(7):705-710.
A more than recent article on stop-stage renal affliction is available.
Patient information: See related handout on kidney failure, written by the authors of this article.
Article Sections
- Abstract
- Symptom Direction
- Initiation of Dialysis
- Advance Care Planning
- References
The prevalence of cease-stage renal disease continues to increment, and dialysis is offered to older and more medically complex patients. Pain is problematic in up to one-half of patients receiving dialysis and may effect from renal and nonrenal etiologies. Opioids can exist prescribed safely, but the patient'due south renal function must be considered when selecting a drug and when determining the dosage. Fentanyl and methadone are considered the safest opioids for use in patients with end-stage renal disease. Nonpain symptoms are common and touch on quality of life. Phosphate binders, ondansetron, and naltrexone can exist helpful for pruritus. Fatigue can be managed with treatment of anemia and optimization of dialysis, but persistent fatigue should prompt screening for low. Ondansetron, metoclopramide, and haloperidol are effective for uremia-associated nausea. Nondialytic management may be preferable to dialysis initiation in older patients and in those with boosted life-limiting illnesses, and may non significantly decrease life expectancy. Delaying dialysis initiation is also an option. Patients with finish-stage renal disease should have accelerate directives, including documentation of situations in which they would no longer want dialysis.
The number of patients with end-phase renal affliction is increasing in the Us, in office because of the epidemic of diabetes mellitus. Dialysis is now offered to older and more than medically complex patients who would not have been considered for handling in the days of express dialysis resources. The prevalence of coronary artery disease in patients receiving dialysis increased from 0.1 percent in 2004 to 21.0 percent in 2007; the prevalence of cancer and chronic obstructive pulmonary affliction increased as well.1 Ii-thirds of patients receiving dialysis take moderate or severe cerebral impairment.2
Symptom management and advance care planning are crucial for these patients. Family unit physicians may be called on to address advance directives or to support patients and families in decisions almost dialysis initiation or withdrawal. In addition, family physicians must be prepared to manage symptoms associated with finish-stage renal illness and conform medication dosages accordingly.
SORT: Central RECOMMENDATIONS FOR Practise
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Fentanyl and methadone are the preferred opioids for use in patients with finish-stage renal affliction. | C | viii, 10, 11 |
| Conservative (nondialytic) direction of terminate-stage renal illness tin can be offered to older adults and patients with multiple comorbidities. | C | 23, 24, 26 |
| Delayed initiation of dialysis (when glomerular filtration rate is 5.0 to 7.0 mL per minute per 1.73 g2) yields equivalent outcomes to early initiation. | B | 27 |
| Patients with finish-stage renal disease should have advance directives, including documentation of situations in which they would want to discontinue dialysis. | C | 31, 34 |
Symptom Direction
- Abstract
- Symptom Management
- Initiation of Dialysis
- Advance Care Planning
- References
End-stage renal disease is associated with a large symptom burden. In one recent study, patients receiving dialysis reported an average of ix symptoms that resulted in dumb quality of life.3 In a 2nd report, symptom brunt and quality of life in advanced renal failure were like to those in terminal malignancy.4 Up to half of symptoms of finish-phase renal affliction go untreated.5 In light of these findings, the Great britain recently adopted national guidelines for symptom management in advanced chronic kidney disease.half-dozen Formal recommendations for renal palliative care have been slower to evolve in the Usa, and symptom management is ofttimes left to family physicians.
PAIN
Hurting is extremely common in terminate-stage renal illness and can outcome from renal and nonrenal etiologies. In a prospective cohort study of 205 patients receiving hemodialysis, 50 percent reported a trouble with pain.vii Musculoskeletal pain was most common (63.1 percentage), followed by dialysis-associated pain (13.6 percent), peripheral neuropathy (12.6 percentage), and peripheral vascular disease (9.7 percent).
Some causes of pain are specific to renal disease. Polycystic kidney disease can cause chronic intestinal pain. Secondary hyperparathyroidism often results in bone pain. Calciphylaxis is a relatively rare cause of astringent generalized hurting that occurs almost exclusively in patients receiving dialysis. Aberrant metabolism of calcium and phosphorus leads to vascular calcification and peel ischemia, which unremarkably presents as a painful rash or wound only tin can rapidly progress to overt necrosis.8 Calciphylaxis is difficult to treat and may justify withdrawal of dialysis in favor of hospice care.
Pain management must take into account the likely etiology of pain likewise as the patient's renal function and dialysis condition. Some analgesics should be avoided, whereas the dosage of others must be adapted. For balmy pain, acetaminophen can be used safely without any dose adjustment.8 Nonsteroidal anti-inflammatory drugs (NSAIDs) should mostly exist avoided in patients with end-stage renal disease because uremia causes platelet dysfunction and increases the risk of gastrointestinal bleeding. NSAIDs should always be avoided in patients receiving peritoneal dialysis.8 In this blazon of dialysis, adequate solute clearance and maintenance of volume balance depends on modest amounts of residuum renal function, which may be threatened by NSAID use.9
For moderate to severe pain, tramadol (Ultram) can be used cautiously merely requires dose aligning and an increased dosing interval; the maximal dosage should not exceed 50 to 100 mg twice daily.10 Many patients will crave opioid analgesics to achieve adequate hurting command. Fentanyl and methadone are considered the safest opioids for use in patients with renal failure10,11 ; other opioids may be used with close monitoring and dose aligning (Table 1six,8,10,eleven and Table 211,12).
Table i.
Opioid Selection in Patients with End-Stage Renal Disease
| Drug | Rubber | Dialysis considerations |
|---|---|---|
| Generally considered condom | ||
| Fentanyl | Metabolized in liver; no active metabolites | Non removed past dialysis |
| Methadone | Fecal excretion; no active metabolites | Not removed by dialysis |
| Use with caution | ||
| Hydromorphone (Dilaudid) | Mostly metabolized in liver, but one active metabolite accumulates in patients with renal failure; reduce dosage and monitor closely | Active metabolite removed past dialysis but may accumulate betwixt sessions |
| Oxycodone (Roxicodone) | Mostly metabolized in liver, simply small amount excreted in urine; reduce dosage and monitor closely | No data; likely to be removed by dialysis based on molecular size |
| Not recommended | ||
| Codeine | Metabolized to morphine; active metabolites accumulate in patients with renal failure; tin cause respiratory depression, hypotension, and narcolepsy | Avoid in dialysis |
| Hydrocodone | Parent drug and agile metabolites accumulate in patients with renal failure; no safety data | Avert in dialysis |
| Meperidine (Demerol) | Agile metabolite accumulates in patients with renal failure; tin cause seizures | Avert in dialysis |
| Morphine | Agile metabolites accumulate in patients with renal failure; can cause myoclonus, seizures, and respiratory depression | Avoid, or use only when decease is imminent |
Table 2.
Methadone and Fentanyl Dosing in Patients with Renal Disease
| Glomerular filtration rate(mL per minute per 1.73 k ii ) | Initial opioid dose (percentage of usual dose) | ||
|---|---|---|---|
| Morphine | Methadone | Fentanyl | |
| > 50 | 100 | 100 | 100 |
| 10 to l | 50 to 75 | 100 | 75 to 100 |
| < 10 | 25 | 50 to 75 | fifty |
Adjuvant medications are oft added to augment opioids. Despite contempo controversy virtually the force of evidence for its use in neuropathic pain, gabapentin (Neurontin) is widely prescribed, and its dosage must exist adjusted for renal function.13 Gabapentin is excreted unchanged in the urine; it can accumulate to potentially toxic levels in patients with renal failure. For patients receiving hemodialysis, a loading dose of 300 mg tin can be given, followed by 200 to 300 mg after each dialysis session.8 For patients who are not receiving dialysis but take creatinine clearance of less than 30 mL per minute per 1.73 m2, a dose of 200 to 700 mg can be given in one case daily.14 Tricyclic antidepressants are mostly avoided in patients with chronic kidney disease; their proarrhythmic potential poses additional run a risk in the setting of fluctuating electrolyte abnormalities. Pregabalin (Lyrica) requires a decreased dosage and an increased dosing interval. Exact dosing depends on the indication and creatinine clearance.15
NONPAIN SYMPTOMS
Nonpain symptoms also contribute to decreased quality of life in patients with renal failure. Lack of energy and pruritus are reported by upwards to 75 percent of patients with stage 5 chronic kidney disease.16 More than half of patients accept drowsiness, dyspnea, or edema16 ; boosted symptoms include dry mouth, muscle cramps, restless legs syndrome, lack of appetite, poor concentration, slumber disturbance, and constipation. Many of these symptoms tin can be managed with simple interventions in the master care setting (Table 3).6,8,17–20 [ corrected] Pruritus tin be managed with phosphate binders, emollients, antihistamines, ondansetron (Zofran), and naltrexone (Revia).6,17 Fatigue tin be managed by treating anemia, encouraging physical activity, and evaluating for low.6,eight Ondansetron, metoclopramide (Reglan), and haloperidol are effective antiemetics for uremiaassociated nausea.6,19
Table iii.
Management of Common Nonpain Symptoms in Patients with End-Stage Renal Affliction
| Symptom | Direction | Example initial dosages |
|---|---|---|
| Agitation and delirium | Haloperidol is safety and commonly used because of its rapid onset of action (reduce dosage by 50 percent); singular antipsychotics require renal dosing; benzodiazepines are rubber but may exacerbate delirium, and are widely used at the cease of life | Haloperidol, 1 mg orally, intravenously, or intramuscularly every 12 hours |
| Anorexia | Ensure adequate dialysis (minimize uremia); evaluate for and care for low, gastroparesis, and dry oral fissure; consider dronabinol (Marinol), megestrol (Megace), or prednisone | Dronabinol, two.5 mg orally before meals |
| Megestrol, 400 mg orally per twenty-four hour period | ||
| Prednisone, ten mg orally per twenty-four hour period | ||
| Dyspnea | Encourage regular physical activeness; ensure optimal fluid residual; employ opioids for refractory dyspnea at the finish of life | Fentanyl, 12.v mcg intravenously or subcutaneously every two hours every bit needed |
| Morphine, 5 mg orally or sublingually; use as needed when death is imminent | ||
| Fatigue | Ensure adequate treatment of anemia; encourage regular physical activity; evaluate for and treat low | Fluoxetine (Prozac), 20 mg orally per day |
| Sertraline (Zoloft), 50 mg orally per day | ||
| Nausea and airsickness | Ensure acceptable dialysis (minimize uremia); ondansetron (Zofran) is safety at usual dosages; consider metoclopramide (Reglan; reduce dosage past 50 percent); consider low-dose haloperidol for persistent nausea | Ondansetron, 4 mg orally every 8 hours |
| Metoclopramide, 5 mg twice per day | ||
| Haloperidol, 0.5 mg orally every eight hours | ||
| Pruritus | Ensure adequate dialysis (minimize uremia); encourage compliance with phosphate binders; use emollients liberally; consider antihistamines, ondansetron, or naltrexone (Revia); ultraviolet B phototherapy may exist used | Hydroxyzine (Vistaril), 25 mg orally every six hours |
| Ondansetron, four mg orally every eight hours | ||
| Naltrexone, 50 mg orally per twenty-four hour period | ||
| Sexual dysfunction | Consider evaluation for depression testosterone levels; evaluate for and treat depression; phosphodiesterase inhibitors are safe if not otherwise contraindicated | Sildenafil (Viagra), 25 mg orally before intercourse |
| Sleep disturbance | Care for pain; evaluate for and treat restless legs syndrome and slumber apnea; avert caffeinated beverages and tobacco; minimize daytime naps; benzodiazepines and zolpidem (Ambien) are condom when indicated in patients undergoing dialysis | Temazepam (Restoril), 15 mg orally at bedtime |
| Zolpidem, 5 mg orally at bedtime |
Initiation of Dialysis
- Abstract
- Symptom Management
- Initiation of Dialysis
- Accelerate Care Planning
- References
The decision to initiate dialysis is usually fabricated by a nephrologist, simply family unit physicians are ideally positioned to collaborate with nephrologists and counsel patients and families when decision making is difficult. This may be peculiarly of import when the patient is older or when there are additional life-limiting diseases.
CONSERVATIVE (NONDIALYTIC) MANAGEMENT
In response to the aging population and trends of dialyzing older and sicker patients, there has been growing involvement in nondialytic alternatives for managing end-stage renal affliction. The Renal Physicians Association and the American Society of Nephrology issued a practice guideline affirming the rights of patients to decline dialysis.21 Nondialytic direction includes conscientious attention to fluid remainder, treatment of anemia, and correction of acidosis and hyperkalemia. Blood pressure and metabolism of calcium and phosphorus must also be monitored. In that location is emerging evidence that dietary modifications may exist helpful in prolonging life and decreasing symptoms.22
Patients, families, and some medical professionals may erroneously retrieve that choosing non to kickoff dialysis is equivalent to stopping dialysis. Although patients who discontinue dialysis die within 1 to two weeks, patients who decline dialysis initiation can alive for months to years. Studies have showed that patients who turn down dialysis have a median life expectancy of half dozen.3 to 23.4 months.23,24 Functional condition generally remains stable until the concluding month of life.25 Several studies have found trivial or no survival benefit with dialysis versus bourgeois direction in older patients.23,26 Any modest survival benefit from dialysis decreases with the presence of comorbid weather condition, especially ischemic heart disease.26 Family physicians tin counsel older patients and those with multiple comorbidities that nondialytic direction is a viable option in stop-stage renal disease.
DELAYED INITIATION
Considerable clinical variation exists in the timing of dialysis initiation. A contempo trial randomized 828 adults to early initiation of dialysis (at a glomerular filtration rate of 10.0 to 14.0 mL per minute per 1.73 10002) or late initiation (at v.0 to 7.0 mL per minute per one.73 g2).27
In 3 years of follow-upwards, there were no differences between groups in mortality, cardiovascular events, infections, or dialysis complications. This trial suggests that delayed dialysis initiation is an acceptable choice, particularly in patients who are unsure that they want dialysis. Delayed initiation may also be practical in patients for whom dialysis would be a significant hardship, such as those who work or have limited social support.
Advance Intendance Planning
- Abstract
- Symptom Management
- Initiation of Dialysis
- Accelerate Care Planning
- References
The five-year survival charge per unit for patients with stage five chronic kidney affliction is 38 percent, less than that of AIDS and many cancers.28 For patients older than 65 years, the v-yr survival rate is only eighteen percent.1 Given this high bloodshed, advance intendance planning is a critical topic to address at all opportunities, such as annual physicals, hospital admissions, and routine role visits.
CARDIOPULMONARY RESUSCITATION
Patients with renal failure have poor outcomes subsequently cardiopulmonary resuscitation (CPR). In one study of 74 patients receiving dialysis who underwent CPR for cardiopulmonary abort, only 8 percent survived to hospital discharge, and only three per centum were alive half-dozen months after CPR.29 These outcomes were significantly worse than those in patients who were not receiving dialysis (12 per centum survival to hospital belch, 9 pct survival six months afterward CPR). Patients who survive CPR often have neurologic compromise or need ongoing mechanical ventilation.
Despite these statistics, many patients with cease-stage renal disease take unrealistically optimistic expectations of CPR. In ane report, 87 percent of patients receiving dialysis reported that they would want CPR in the event of cardiopulmonary arrest.thirty Blacks were significantly more likely to want CPR than whites (adapted odds ratio = 6.56, 95% conviction interval, 2.57 to 22.27). Family unit physicians can help educate patients virtually the low likelihood of successful CPR in the setting of end-phase renal affliction. They tin too document do-not-resuscitate status if necessary.
Accelerate DIRECTIVES
Advance directives (i.e., a living will and durable power of attorney for health care) can guide physicians in stop-of-life decision making. In add-on, patients who complete written advance directives are more likely to informally discuss their wishes for specific medical interventions with their families.31 As many as one-half of patients who receive dialysis do not have advance directives.32 Ane study showed that less than 10 pct of patients had discussions well-nigh end-of-life care with their physicians, and 61 percent reported that they regretted their decision to first dialysis.33
Nearly advance directives do non describe situations in which a patient would no longer desire dialysis. Withdrawal of dialysis is mutual in stop-stage renal illness; therefore, illness-specific accelerate directives that include dialysis withdrawal have been proposed.34 Family physicians can facilitate preemptive conversations virtually these bug with patients and their conclusion makers.
HOSPICE ELIGIBILITY
Patients whose only life-limiting diagnosis is stop-stage renal disease are not eligible for the Medicare hospice benefit while they are receiving dialysis. If patients have another terminal diagnosis, they may receive concurrent hospice and dialysis benefits under Medicare. For instance, a patient receiving dialysis who develops metastatic cancer may continue dialysis while receiving hospice services for cancer.35 Patients who stop dialysis are always eligible for hospice care and should be routinely referred. However, only 41.9 percent of patients who withdrew from dialysis in 2001 and 2002 received hospice services.36 Hospice care decreases the cost of care and increases the likelihood of dying at abode after dialysis withdrawal.36
Data Sources: A Medline search was conducted using the cardinal terms stop-phase renal disease and kidney failure, chronic. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. The results were then combined with the following search terms: pain, palliative care, accelerate care planning, quality of life, and terminal care. Besides searched were the Cochrane Database, the National Guideline Clearinghouse, Essential Evidence Plus, and Fast Facts for Palliative Intendance. Search date: Jan 28, 2011.
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REFERENCES
prove all references
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4. Saini T, Murtagh FE, Dupont PJ, McKinnon PM, Hatfield P, Saunders Y. Comparative pilot study of symptoms and quality of life in cancer patients and patients with terminate stage renal disease. Palliat Med. 2006;20(six):631–636.
5. Claxton RN, Blackhall L, Weisbord SD, Holley JL. Undertreatment of symptoms in patients on maintenance hemodialysis. J Pain Symptom Manage. 2010;39(2):211–218.
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31. Holley JL. Accelerate care planning in elderly chronic dialysis patients. Int Urol Nephrol. 2003;35(iv):565–568.
32. Holley JL, Hines SC, Glover JJ, Babrow AS, Badzek LA, Moss AH. Failure of advance care planning to elicit patients' preferences for withdrawal from dialysis. Am J Kidney Dis. 1999;33(4):688–693.
33. Davison SN. End-of-life intendance preferences and needs: perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol. 2010;v(2):195–204.
34. Bartlow B. In search of an accelerate directive that works for terminate-stage renal disease patients. Hemodial Int. 2006;10(suppl two):S38–S45.
35. Thompson KF, Bhargava J, Bachelder R, Bova-Collis R, Moss AH. Hospice and ESRD: knowledge deficits and underutilization of program benefits. Nephrol Nurs J. 2008;35(5):461–466.
36. Murray AM, Arko C, Chen SC, Gilbertson DT, Moss AH. Utilize of hospice in the United states dialysis population. Clin J Am Soc Nephrol. 2006;1(6):1248–1255.
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