What is Concurrent Hemodialysis (HD)?
Concurrent hemodialysis refers to the provision of hemodialysis treatments simultaneously with hospice care for patients with end-stage renal disease (ESRD) who are near the end of life. This represents a policy change needed to improve access to palliative care for dialysis patients, as current Medicare regulations create barriers to receiving both services together. 1
Current Policy Barriers
Under existing Centers for Medicare and Medicaid Services (CMS) regulations, dialysis patients face severe limitations in accessing hospice care at the end of life because hospice typically requires patients to forgo life-sustaining treatments. 1
The current system creates financial disincentives for providing concurrent hospice and dialysis, forcing patients to choose between continuing dialysis or receiving hospice services. 1
CMS policy promotes a "one-size-fits-all" approach to dialysis that discourages individualized end-of-life care planning. 2
Recommended Policy Changes
Payment for concurrent hospice and dialysis should be implemented to remove legislative and regulatory barriers preventing ESRD patients from accessing appropriate end-of-life care. 1
A separate set of ESRD Quality Incentive Program metrics should be developed for seriously ill patients undergoing dialysis, including documented shared decision-making, advance care planning discussions, completion of advance directives, rate of referral to hospice, and out-of-hospital death. 1
Funding for demonstration projects exploring medical management without dialysis as a treatment option is needed. 2
Clinical Context
For patients with limited life expectancy or severe comorbidity, conservative management without dialysis represents a reasonable alternative that should be supported by comprehensive palliative care programs. 3
The decision to continue or reduce dialysis intensity in older patients with terminal kidney insufficiency should integrate life expectancy, comorbidity, functional status, and patient preferences. 2
Palliative care and hospice referral are indicated for patients who decide against renal replacement therapy or choose to discontinue dialysis. 4
Important Caveat
The term "concurrent HD" in clinical practice most commonly refers to the policy issue of simultaneous hospice and dialysis services rather than a specific dialysis technique. This differs from "bimodal dialysis" (BMD), which refers to the combination of peritoneal dialysis and hemodialysis in the same patient (typically 5-6 days of PD with 1-2 HD sessions weekly). 5