Can an adult patient with end‑stage renal disease on thrice‑weekly hemodialysis and multiple comorbidities (e.g., diabetes, cardiovascular disease, frailty) be enrolled in palliative‑care services while continuing dialysis?

Yes, Patients on Hemodialysis Can and Should Be Enrolled in Palliative Care

Patients with end-stage renal disease receiving hemodialysis can absolutely be enrolled in palliative care services while continuing dialysis—this is called "concurrent hospice and dialysis" or "palliative dialysis," and it represents an essential but underutilized model of care for seriously ill dialysis patients. 1

The Evidence Supporting Concurrent Care

Current Policy Barriers vs. Clinical Need

• The American Journal of Kidney Diseases explicitly recommends that CMS and other payors remove financial and regulatory barriers to enable concurrent hospice and dialysis services for terminally ill patients 1
• Current policies create significant access problems: approximately 62% of patients who stopped dialysis accessed hospice, compared with only 16% of those who continued dialysis 2
• Many hospices restrict enrollment of patients receiving dialysis, creating artificial barriers that prevent patients from receiving optimal end-of-life care 2

When Palliative Care Is Indicated

All patients with ESRD on dialysis who have severely limited life expectancy, low quality of life, refractory symptoms, or progressive deterioration should receive integrated palliative care—whether they continue or discontinue dialysis. 1

Specific indicators include:

• Age ≥75 years with multiple comorbidities 1
• Frailty or functional impairment 1
• Cognitive impairment 1
• "No" response to the Surprise Question ("Would you be surprised if this patient died in the next year?") 1
• High symptom burden (fatigue, pain, dyspnea, pruritus, sleep disturbances) 1, 2

How to Implement Concurrent Palliative Care and Dialysis

Frame Dialysis as a Comfort Measure

• When dialysis serves patient-centered goals (e.g., symptom control, attending important life events like a wedding or birth of a grandchild), justify it as "palliative dialysis" focused on comfort rather than disease modification 1, 2
• This reframing helps overcome hospice enrollment barriers and aligns treatment with what matters most to the patient 2

Essential Components of Concurrent Care

Systematic symptom assessment:

• Use validated renal-specific tools at every encounter: Edmonton Symptom Assessment Scale-Renal (ESAS-R) or integrated Palliative Care Outcome Scale-Renal (iPOS-R) 1, 2
• Nephrology providers are often unaware of patients' most troublesome symptoms without systematic assessment 1, 2

Advance care planning:

• Conduct ongoing shared decision-making discussions using open-ended prompts: "What are you hoping for?" and "What does quality of life mean to you?" 2
• Document goals of care and ensure they are accessible across all care settings 1, 2
• Tie reimbursement to comprehensive advance care planning processes 1

Interdisciplinary coordination:

• Coordinate care among nephrology, palliative care clinicians, social workers, and chaplains 2
• Assess spiritual needs with structured tools like FICA (Faith, Importance, Community, Address in Care) 2

Critical Pitfalls to Avoid

Do not assume dialysis must cease for hospice enrollment. This is the most common and harmful misconception—support concurrent care when aligned with patient goals. 2

Do not rely on disease-focused quality metrics (standard ESRD Quality Incentive Program measures) for seriously ill patients. Instead, prioritize patient-centered outcomes: documented advance care planning, completion of advance directives, symptom assessment scores, and out-of-hospital death rates. 1, 2

Do not omit systematic symptom assessment. Lack of structured evaluation leads to unrecognized high-burden symptoms that severely impact quality of life. 1, 2

Do not provide one-size-fits-all dialysis care. Seriously ill patients constitute approximately 20% of the kidney disease population and have different prognoses and needs than those who are not seriously ill—they require focused supportive care aligned with their values and preferences. 1

The Rationale for Policy Change

• The American Journal of Kidney Diseases calls for CMS to operationalize financial incentives including payment for concurrent hospice and dialysis, and separate ESRD Quality Incentive Program metrics for seriously ill patients undergoing dialysis 1
• Current financial incentives promote disease-oriented care such that most patients begin dialysis without realizing they have alternatives, and terminally ill patients face barriers to receiving the best end-of-life care through hospice 1
• Critical Care guidelines state that patients who initially receive time-limited dialysis trials due to uncertain prognosis should be offered integrated palliative care from the outset 1