From the Guidelines
A patient with Stage IV Chronic Kidney Disease (CKD) who refuses dialysis if it becomes necessary may qualify for hospice care, but qualification depends on several factors, including a life expectancy of six months or less, as supported by the most recent study 1. The primary requirement for hospice care is a life expectancy of six months or less, which must be certified by two physicians. For CKD patients refusing dialysis, this prognosis is often supported by declining kidney function (GFR typically below 15 ml/min), symptoms of uremia, comorbidities, nutritional decline, and functional status deterioration.
- Key factors to consider for hospice eligibility include:
- Life expectancy of six months or less
- Declining kidney function (GFR typically below 15 ml/min)
- Symptoms of uremia
- Comorbidities
- Nutritional decline
- Functional status deterioration While Stage IV CKD alone (GFR 15-29 ml/min) may not immediately qualify someone for hospice, the decision to forgo life-sustaining dialysis when clinically indicated significantly changes the prognosis.
- Patients should document their treatment preferences through advance directives and POLST forms, as recommended by recent studies 1. The hospice team would provide symptom management for uremic symptoms, including medications for nausea, pruritus, pain, and agitation, along with emotional and spiritual support.
- Early palliative care consultation is recommended to discuss goals of care and symptom management, even before hospice eligibility is confirmed, as suggested by recent research 1.
From the Research
Eligibility for Hospice Care
To determine if a patient with Chronic Kidney Disease (CKD) stage IV qualifies for hospice care, several factors must be considered.
- The patient's current health status and prognosis
- The patient's refusal of dialysis if it becomes necessary
- The availability of palliative care options
Palliative Care Options
Palliative care is a branch of medicine dedicated to the relief of symptoms experienced during the course of illness 2.
- Renal palliative medicine or kidney supportive care is an evolving branch of nephrology that incorporates the principles of palliative care into the care of CKD and ESRD patients
- Conservative (non-dialytic) management is a legitimate option for frail, elderly CKD patients in whom dialysis may not lead to an improvement in quality or duration of life 2
- Patients with advanced CKD have a high symptom burden that often worsens before death, and palliative or supportive care should be routine for conservatively managed CKD patients 2
Hospice Care
Hospice care should be offered to all patients who are expected to die within the next 6 months, and supportive care should be provided to all CKD patients managed conservatively or with dialysis 2.
- A study found that elderly patients who choose not to have dialysis as part of shared decision making survive a median of 16 months, and about one-third survive 12 months past a time when dialysis might have otherwise been indicated 3
- Patients with CKD experience physical and psychosocial frailty and feel ambivalent about prolonging life, and caregivers believe in providing relief from suffering, but are uncertain about making decisions regarding dialysis therapy initiation and discontinuation 4
Conclusion Not Provided as per Request
Instead, the information provided highlights the importance of considering palliative care options for patients with CKD stage IV, including hospice care, and the need for respectful and attentive communication to empower patients to convey their values and preferences about their own care 5, 6.