Palliative Dialysis: Shifting the Palliative Care Paradigm for End Stage Renal Disease

Palliative Dialysis: Shifting the Palliative Care Paradigm for End Stage Renal Disease



good morning everyone welcome again to palliative care Grand Rounds our presenter this morning is going to be Phil Ramos and Phil's from Corpus Christi Texas he attended the University of Texas at Austin and received a bachelor's degree in biochemistry and I apologize I'm out of breath I ran in from my car to get here I'll just put that outfit felt earned his medical degree in 2000 from Baylor in Houston Texas and he stayed on at Baylor for his internal medicine medicine residency followed by a chief year he finally left Texas to complete his nephrology fellowship at Vanderbilt Phil moved to Denver Colorado in 2009 to enter nephrology practice and was medical director at Da Vida outpatient dialysis after 10 years of Nephrology practice he decided to transition to a new career in palliative care and hospice medicine prior to starting his second fellowship he briefly served as a hospice medical director with the Denver Hospice good morning everybody my name is Phil Ramos also known as dr. Phil I am so happy to be here today presenting Grand Rounds to my friends and colleagues it's truly an honor so thank you so much I first want to start off by saying that three years ago if you'd told me I'd be presenting Grand Rounds today Mass General Hospital's ether dome I would have told you that you must be crazy absolutely crazy why would I be presenting Grand Rounds today and the reason why I would say that is because I was a nephrologist in private practice for many years in beautiful Denver Colorado I was a fully invested partner in a large group I was a medical director of two dialysis units and had three offices in the northern suburbs of Denver I had ten weeks of annual vacation and a four-day work week so yeah why would I be here right good question so I would like to briefly describe a typical day of my practice in Denver nephrology practice is located in three different venues the the hospital the dialysis unit and the outpatient clinic my days would start very early in the hospital ICU seeing the sickest of the sick on dialysis I would see follow-ups and new consults in the hospital and then I would drive to my clinic seeing chronic kidney disease patients who some of them would end up on dialysis someday then I would go to the dialysis unit and round on dialysis patients my typical day I'd be driving back and forth from these different locations and I would learn how to think fast and move fast and in the course of the day I'd be asked to stamp out small fires of disease or I would have to address large tsunamis of life-and-death situations and it was non-stop sometimes I would have colleagues calling about mutual patients and also I would get calls from patients and their families concerned about their kidney care it was in this environment that I actually developed a passion for palliative care because I saw so much suffering in these locations but I grew very frustrated because I could only keep them alive on dialysis and I could not palliate them so I became burned-out and during this time my dad also was diagnosed with stage 4 cancer so I made the decision to leave practice and pursue a career in palliative care and that's why I'm here today so just short quick story about that so I am very proud to present the palliate approach to dialysis care the shifting of the treatment paradigm for end-stage renal disease these are my financial disclosures they do not make me bad people so I like to start out by describing the need for palliative care and the American end stage renal disease population then I'll follow that by discussing barriers to pallet the palliative approach to dialysis care in the outpatient setting and that will end with some possible models apply to care for ESRD patients so I'll start with one of my patients in my dialysis clinics use the 62 year-old man with the advanced kidney disease due to diabetes who is mitad to the hospital and found to have newly diagnosed diagnosed cirrhosis like many of my patients on with kidney disease he crashed onto dialysis in the hospital and he was diagnosed with end-stage renal disease we accepted him to our outpatient dialysis clinic with open arms I met him he had a tunneled catheter he would develop severe hypotension on dialysis which make dialysis blood cleaning and fluid removal very difficult he had a very hard time adjusting to dialysis and he told me he hated dialysis the only reason why I was doing it is because his family wanted him too he said that his only hope was to receive a kidney liver transplant and he worried that he would spend the rest of his life on dialysis he would grow very frustrated because his low blood pressure would prevent us from removing significant fluid on dialysis and he would refuse makeup sessions to catch up this led to weekly paracentesis to remove volume from his 'm abdomen over the coming months he had multiple hospital admissions due to complications from cirrhosis because of his declining health he was told by hepatology in one of his hospitalizations that he was no longer a candidate for transplant when I saw him next he was devastated he was also suffering extreme fatigue weight loss decreased appetite and severe peripheral neuropathy I offered to refer him to palliative care outpatient and he accepted but he told me that he was not ready to die and he wanted to continue to be a full code so my dialysis visits were very very focused on disease metrics of care on dialysis so I was very focused on number one ensuring that patients had enough blood clean cleaning of uremic toxins this is what we call dialysis adequacy also removing enough fluid during dialysis and this is ensured by a three times per week dialysis schedule and hemo as well as each session lasts in three to four hours I was also very interested making sure these patients had permanent access for dialysis AV fistula Zoar grafts they had catheters I aggressively would refer them to a surgeon for a fistula because these catheters are dangerous they're associated with life-threatening infections I was also treating all their other issues like anaemia and malnutrition bone disease and ensuring they had a proper renal diet but I left a lot of symptoms on the table because I I just didn't have the time or the skill set to treat them for instance chronic pain is very common in the asari population about 50% suffer from it and of these 80% rate their pain moderate to severe depression is extremely common 40% suffer from depression which has been found to be an independent risk factor for mortality in this population if it wasn't for all these symptoms that I couldn't manage there is also an equal amount of psychosocial issues we do have social workers in our dialysis units they're very overworked and they deal with these issues plus advanced care planning but many surveys have said that patients dialysis patients want their nephrologists to lead discussions regarding goals of care and Vance care planning but I simply didn't have the time so how many patients are living this life on dialysis in 2016 the number of new cases of yes Rd were approximately 125,000 patients the majority of which were 65 years and older defined as older aged or 75 years and older defined as advanced age the prevalence in ESRD in 2016 rose to 725 thousand patients on dialysis and of these the prevalence was highest in the older and advanced age groups the exact populations that suffer the most disease burden due to multiple core morbidities as well as frailty so regarding mortality rate the the Medicare dialysis population has a mortality rate that's 10 times that of the general Medicare population the one year mortality of an older age dialysis patient is approximately 30% the one-year mortality of an advanced stage dialysis patient is approximately 40% in surveys have studies have shown that the Medicare dialysis population has a higher mortality rate than those with cancer diabetes and cardiovascular disease in the Medicare population so what are the the risk factors for high mortality in the first year after starting dialysis Melissa walked Herrmann over the VA Boston published data from a longitudinal survey Medicare beneficiaries over the age of 65 in it she found that 55% of dialysis patients over the age of 65 were died within one year starting dialysis was very concerning was the inpatients eighty five years in older on dialysis seventy percent of them were dead one year after starting dialysis after multivariate analysis she found that the highest risk factors for one-year mortality in this cohort were dependence on activities daily living advanced age 85 years or older the presence of four or more core morbidities in dialysis initiation as an inpatient I thought this was a very interesting data because we in palliative care see so many cancer patients this is data out of Ontario Canada which was a mortality study comparing the newly diagnosed Sardi patients with the newly diagnosed cancer patient and in it it found that patients with ESRD had a lower survival probability than those with colorectal cancer as well as breast and prostate cancer in women and men respectively it was also very interesting is that the patient that was over 70 years old on dialysis had a similar 10-year survival compared to as similar as patients with lung cancer and pancreatic cancer so how are these patients spending their final month of life in the dial-in in in in the final month of life well many of these patients the elderly dialysis patients are saying their end of life in the hospital unfortunately so Wang and colleagues in 2012 did a mortality study characterizing the end-of-life patterns of care in the hospital in the final month of life this was compared to Medicare beneficiaries with cancer and heart failure she found that the dialysis patient in the final mental life 76% of them were hospitalized at the end of life 50% of them were admitted to the ICU and 30% of them had in sense a procedure like mechanical ventilation or CPR what was very concerning was that 20 percent of these dialysis patients in the final mental life were referred to hospice only 20 percent and this was compared to 55 percent of cancer patients and 40 percent of heart failure patients six years later long again published mortality data this time in a VA cohort and she again showed that Medicare dialysis patients in the final month of life utilize high-intensity patterns of end-of-life care what was also interesting and this in this cohort is she analyzed advanced kidney disease patients who decided not to pursue dialysis in their final month compared to decedent's who receive dialysis until the end of life the patients that decided not to pursue dialysis or less likely to be hospitalized less likely to have an intensive procedure or died in the hospital well it was also very interesting is that these patients that that did not pursue dialysis had a higher likelihood of having inpatient palliative care consultation as well as being enrolled in hospice it's worth noting though that even these patients who did not seek dialysis over 50% of them still were admitted to the hospital and and this suggests that even though they transition to hospice they first started out with aggressive care and decided not to dialyze so the data has been very clear in multiple studies that ESRB patients are less likely to participate in advanced care planning so karela and colleagues analyzed a cohort of nursing home residents and found that the ESRD patients in the final month of life or the final year of life were less likely to have treatment limiting directives or a document in health care proxy and this was compared to residents who suffered from cancer COPD and dementia so I hope with all this data that presenting presented that I think we could all agree that palliative care is very important in the ESRD population particularly in the elderly frail with with multiple comorbidities their prevalence is increased seen through the years and will continue to do so the mortality rate in these older populations is high many of them experienced end-of-life in the hospital they do not have advanced care planning and many of them are not referred to hospice at the end of life so considering that there's a high morbidity mortality in these older populations it's it's very easy to see that the burdens of dialysis care frequently outweigh any benefits for them and I would propose if we offer a poly approach to dialysis in patients in which we shift the focus in the emphasis to minimizing burdens of these very rigid dialysis schedules like three times a week and also shifting the focus away from diseased disease Metrix dialysis care perhaps these patients will be better better treated and more comfortable at the end of life with some dialysis so what is the Palio approach to dialysis care when the ESRD patient nears the end-of-life the emphasis of dialysis care shifts to an increased focus on symptom control and goals to care to ensure quality of life and comfort so instead of those metrics that I described earlier that I did on rounds like getting fistulas in these patients ensuring adequate dialysis with three times we chemo dialysis and also aggressively treating anemia and hypertension and bone disease that we actually shipped it we go into a patient-centered approach where for some patients a catheter would be acceptable for dialysis if they choose so and they have less than a year prognosis so they didn't they don't want surgery also allowing a more relaxed schedule of dialysis maybe once or twice a week only just to palliate their uremic symptoms in Bal your homework overload so that they have more time at home with family before the end of life it also relaxed the treatment of anemia bone disease and just palliate these symptoms with medicines as needed and also liberalize their diet for comfort so we want to worry about so much about phosphorus or potassium so this sounds like this may may work in the dialysis patient populous in a small amount well why is this not being done now well there's actually three barriers that I want to discuss regarding this approach in the outpatient setting this is not an exhaustive list but I think these are the most important the first one is a lack of comfort inadequate palliative care exposure during an apology fellowship that leads to practitioners and follow G being unprepared also fiscal barriers and how Medicare reimburses outpatient dialysis and the last one would be the inability for concurrent reimbursement of ESRD and hospice Medicare benefits so at first like to start off that there's multiple reasons why neurologists are not conducting serious illness conversations I think this was best articulated by doctors Mandel Bernanke and block over at the Brigham when they had a review article published about the serious illness conversation in ESRD in it they described that there might for this might be because page nephrologists don't have the time they don't feel it's their responsibility they don't want to upset their patients they feel that there's too much prognostic uncertainty to have a good discussion and they're also insecure with their communication skills personally in my practice I just didn't have enough time I thought and I also didn't have the training I just didn't I felt insecure in in my my skills so an interesting cross-sectional online survey was conducted in 2013 of second year renal fellows in us fellowships and 95% of them said they thought it was very important to have palliative care skills taught during their fellowship for the future dialysis patients however 50% less than 50% of them said that they were taught how to assess and manage pain in dialysis patients less than 50% were taught how to determine when to referred to palliative care and hospice and or two how to deal with a patient's request to stop dialysis less than 50% were taught how to conduct a family meeting of these these u.s. renal fellows 70% of them said that they present they performed over 10 renal biopsies and had direct supervision and most had feedback but unfortunately the majority of renal fellows conducted very few family meetings of any and the few that actually did over 10 during their fellowship less than 10% had direct supervision and almost none of them had any feedback in my my nephrology fellowship at Vanderbilt they there didn't even have a division of palliative care at the time I did not conduct one family meeting I was not even told how to it was even mentioned to me as a possibility now my program director at Vanderbilt she says that there is a division of palliative care it's very very well regarded and these renal fellows there are now required to participate in a two-week inpatient palliative care elective so I think this is a step in the right direction I just hope that more nephrology fellowships are incorporating palliative care training in their fellowships so the next barrier deals with how Medicare pays outpatient dialysis so a brief history lesson in 1965 Medicare was passed to ride medical insurance to Americans 65 years and older but it did not extend coverage to end-stage renal disease at the time kidney failure was a fatal disease very few academic centers were offering dialysis but as it became clear that dialysis was going to be a chronic therapy that was going to be available to Americans policymakers are very concerned that insurance was going to be a barrier to receive dialysis for most Americans this led to the Medicare ESRD benefit in October in 1972 the democrat-controlled Congress passed the Social Security Amendment in 1972 President Richard Nixon passed it and signed it into law one week before the presidential election this amendment extended coverage to all ESRD patients less than 65 years of age so an 18 year old could receive Medicare as long as the patient had worked enough to qualify for siliceous security so this was actually enacted in 1973 and it was the first Medicare entitlement that actually extends coverage to his specific diagnosis the first of its kind at the time in 1973 the ESRD population was only 55 thousand patients most of them were young people who wanted to use dialysis to rehabilitate to return to work and 1954 the first successful kidney transplant was was performed at the Brigham and Women's Hospital and the hope was that most of these patients would get a kidney transplant policymakers did not believe or dream that the prevalence would increase to what it is today a population mostly being of elderly disabled patients who are unable to work that are using dialysis to prolong life and not to rehabilitate at the time the policymakers did not believe that yes Rd care would be so expensive to Medicare in 1973 the average cost of dialysis was $20,000 per patient per year in 2016 hemodialysis $90,000 per patient per year in peritoneal dialysis was seventy six thousand dollars per patient per year 2016 the the annual Medicare budget for ESRD costs was thirty-five billion dollars and this accounted for seven percent Medicare paid claims even though that yes rd population represents less than 1% of the total Medicare population so to address these high expenditures in the asari population Medicare changed its reimbursement to facilities in 2011 it started with the prospective payment system called PPS and what it did was that it it lumped all the dialysis costs the treatment the drugs the labs into one payment per treatment to the facilities and this bundle if you will was approximately $230 per treatment in 2017 it next started the quality incentive program Equipe in 2012 where it actually established performance metrics on clinical outcome measures that were graded at the depth at the facility level so a payment was linked to performance and actually a facility could be penalized reimbursements if they did not perform up to a specified level and then in 2015 Medicare started a new payment model in which legal partnerships called ESRD seamless care organizations or ESCOs were created these organizations were partnerships of dialysis companies and nephrologist were expected to come up with new innovative ways to treat their dialysis patients they were also going to be financially responsible for their clinical outcomes so these organizations could make money if they had good clinical outcomes and reduce hospitalizations but they could also lose money if too many of their patients were being hospitalized so considering that hospitalizations represent about 40% the SRD costs for medicare per year these organizations could lose a lot of money so the SRD quipped the Equality incentive program is the first pay for performance program in Medicare history I would look monthly at these clinical measures and some of them are actually measures already mentioned like vascular access as well as dialysis adequacy how well we clean the blood and let's say for instance your facility had a lot of catheters and you would be negatively scored if you had a nut patients below what was considered adequate dialysis you would be negatively stored the other measures such as patient surveys submitted from the facility hospitalization rates transfusions hypercalcemia were all measured there are also safety and reporting parameters that that would be factored into the total performance score this score at the facility level it was but if it was between 60 and 100 then Medicare reimburses a hundred percent of the payments for all the Medicare patients however if it's less than 60 then there is a graded reduction in payment to maximum penalty of two percent so considering that Medicare is a primary insurer for ninety percent of u.s. Rd patients a facility could lose a significant amount of money if they're not performing well I mentioned this because what if we had a facility that had a lot of palliative dialysis patients and it was acceptable for a lot of them to have catheters and receive palliative dialysis not the standard of care amount of dialysis well you could see that these facilities would actually lose money but they're actually doing the right thing they're advocating for their patients and those other patients that are not doing palliative dialysis they're doing really well with them but in Medicare's eyes not so much so what makes it even worse is that Medicare actually posts these scores online and a website called dialysis facility compare so patients and families could look online compare scores between clinics and conclude certain things well this is based on a five-star scoring system so this is what I call Yelp for dialysis units which is a good thing transparency is great but the things if you can imagine some patients and families might say wow this is this dialysis unit has only three stars they must have giving terrible you know care but in actuality they just have a lot of dialysis patients that are getting palliative dialysis and it's falsely bringing down their scores so a facility could actually lose future business on the impression that they give substandard care so this is an example on the right of my dialysis unit actually in Westminster and my competitor is on the Left down the street and my unit got five stars for clinical outcome measures compared to three stars to my competitor my competitor had five stars on the patient experience surveys but for some reason my my dialysis unit didn't publish my surveys the patient I don't know why I need to call them but I guarantee you they're really good so but basically you know there's so many factors against a poly approach to dialysis because the current payment model disincentivizes palliative dialysis and if you have the juxtaposition of incentivized patient focus re disease focused metrics with individualized palliative patient centered approach this will create conflict between the dialysis management and the nephrologists because they have an interest in seeing their facility be successful financially but they're also charged with advocating for the patient to do what's right medically for them it also creates conflict would be that patients whose goals of care do not align with this incentivize disease focused approach will be very unhappy so but Medicare does is they put in all these performance metrics into one silo they don't really care if patients goals of care or poor prognosis would align more with palliative they great area that everybody the same so Medicare could perhaps incentivize and palliative care metrics or the very least not penalize facilities whoo patience what some patients want to receive palliative dialysis maybe we could lift some of this financial burden from the facilities but until then I don't think it's going to happen because they literally cannot afford it they want to do the right thing for their patients but they don't want their facility to possibly close down or have to lay off employees part situation so the third barrier is how a Medicare pays for both hospice and dialysis as you know the hospice benefit covers care for the terminal illness if the prognosis is six months or less some people don't know but actually if a dialysis patient has a terminal condition which is not related to us rd they actually can receive both dialysis and hospice coverage by Medicare so the dialysis patient has let's say cancer that's not related to us Rd if they choose to they could receive dialysis ambi and it's a hospice and it will be covered how about if the terminal diagnosis is ESRD are related to this yard ESRD well Medicare will only pay for hospice not dialysis and the issue at this is that if the dialysis patients wishes to continue dialysis then the hospice agency would be financially responsible for all dialysis care well earlier I mentioned that the cost of one hemodialysis treatment was $230 well the cost of routine hospice care per day is $150 so a hospice agency cannot afford to offer dialysis care to any patients that would wish for it and this is very difficult because a patient has to abruptly withdraw from dialysis to receive Hospice well considering that after withdrawing Phi dot from dialysis and an Urich ESRD patient has approximant give enough time for the patients or the families to prepare for death they don't have enough time to say goodbyes and finish unsubtle business they don't have time to actually meet the hospice team so that they could felt some rapport beforehand so this type of approach really really is fear driven there's a lot of anxiety on the patients and families because they feel that they're gonna be unsupported and suffer at the end of life it's not surprising that many of these Medicare the dialysis patients the smallest share of Medicare spending for them goes to hospice care if you look at the small sliver that's maroon and on the top represents hospice expenditure this is not surprising considering the all-or-none approach to dialysis and hospice in this population and it's also not surprising when you consider that many of these ESRD patients are not having serious illness conversations or advanced care planning early on in their disease course so many of these patients end up in the hospital at the end of life and they end up transitioning hospice very late if at all so I would propose that if we had earlier palliative care referral right way at the initiation of dialysis then maybe we could have a smoother transition to hospice care that's not crisis driven and in the hospital at the end of life they could actually be at home and it could be somebody taking care of them they never have to worry about being in the hospital but we need palliative care involved so what what how can we overcome these barriers well I think in the provider level I think nephrologists and apology fellows should be better prepared with palliative care skills coming out of training I think CME should be offered to practicing neurologist to learn these communication skills and I also think that we and palliative care need to reach out to our nephrology colleagues and offer our assistance our education help devise models of care for ESRD I also believe that Medicare needs to change their reimbursement for dialysis so they're not penalized seeing dialysis facilities if patients choose a palliative care route they should also incorporate palliative care measures into the ESRD quip and also perhaps incentivize prayer to peritoneal dialysis and reimburse for staff assist at home dialysis I'll mention a little bit about this shortly also I believe that Medicare should allow joint ESRD in hospice benefit and those that are most at risk so that they are supported if they want to do palliative dialysis if the terminal diagnosis is yes or D and then perhaps s Kousaka partner with palliative care providers to broaden the care for ESRD patients so quickly peritoneal dialysis is a modality performed at home less than 10 percent of us dialysis patients perform peritoneal dialysis which is the opposite of what we see globally most countries around the world offer most commonly peritoneal dialysis and very few actually do chemo it's less costly as I mentioned compared to hemodialysis and it has less symptom burden compared to the hemodialysis and why because it's a very slow gentle daily form of dialysis at home which would be a perfect match for these elderly patients like with heart failure for instance you know who can't tolerate hemo and it could also fit into a very good palliative model in Canada and European countries they actually cover for staff assistant nursing care for patients who need help during peritoneal at home we don't have that at the US but if we did I think it would actually fit into a really nice model let's say home based palliative care or home based hospice and where the visiting nurses are going to be you there anyway and then maybe they could help them with their palliative dialysis at the end of life so I mentioned ESCOs and I think the ESCOs can pair up with the palliative care providers and not be great because then we could offer these enhanced models of care than Medicare wants but I think we have to be very careful at the same time to avoid conflicts of interest because as I mentioned these organizations could actually financially profit if these patients are not being hostile eyes and if we we give and offer a conservative approach to their care in dialysis is not offered then they'll have less hospitalizations so I believe if we to avoid conflicts of interest perhaps making sure that at least the palliative care providers do not have a financial stake in the organization so that they could give unbiased information and advice there's going to be a very very tricky way to navigate this future and I think Medicare also has to be watching and have some regulation to make sure that we protect the patient's so this is a possible model I think that could work a dialysis initiation we have a palliative care team screen and perform goals of care and advance care planning and if the patient's choose to have life prolongation rehab they want aggressive care then we'll go on with the usual disease focused model of care of described but for those patients who are most at risk they should have regular palliative care follow-up with one of our teams to have symptom management advice as well as ongoing rules of care if the goals of care shift at some point during their dialysis journey then at that point is when we switch the approach to a palliative model for a time-limited trial and if the patient hasn't had a fistula place then they keep the catheter they we can relax their dialysis schedules we could palliate anaemia and bone disease liberalize the diet and then at some point with the palliative care team patient family we could plan a hospice transition that's outside of the hospital and they're comfortable at home and with the plan of withdrawing from dialysis I think that this could work but again I think some of the barriers from the financial standpoint needs to be worked out this could also be started at dialysis initiation so the patient's just choose this type of approach you know they could start off with it and go on to the end of life also advanced kidney disease patients like stage 5 CKD and they decline dialysis that's fine we could do an initial pallet palliative care screening but we also have to realize some of these patients actually might be doing well for many months to years it's only when they start feeling uremic then we could transition them to hospice I actually had several patients like this like octogenarians that didn't want dialysis and the Kratt knees were like 5 and I was like wow you're healthy you don't need I alysus and they were so happy but there's they were like that for years you know so I think we could have follow up with these patients it just might take a little bit of time for them so let's return to our patient case mr. RS went to outpatient palliative care he was an interested he wanted to live he didn't really see the big picture of how it could be beneficial unfortunately he was readmitted to the hospital for GI bleed and during this hospitalization he said you know he was done he didn't want to come back to the hospital he changed his codes test DNR the inpatient palliative care service saw him and patient decided to transfer to home hospice his terminal diagnosis under hospice care was cirrhosis and then I was told that you know he still wanted some hemodialysis maybe like 2 times per week for a couple weeks because he wanted to make it to Thanksgiving and his last wish was to share Thanksgiving dinner with his family and watch football which he did so we did it we made sure his dialysis was you know 2 hours you know twice a week we just got enough flew off enough fluid and after da Thanksgiving week he would drew from dialysis and he died peacefully at home five days later this was only one patient that I had that did this many others weren't so fortunate I would arrive to the dialysis unit one day and they said well mr. Smith's not here and I said well what happened he died in the hospital and I didn't never had any follow-up you know I kind of saw it coming their their elderly there's risk factors and it just would be like that so so I hope that palliative care becomes a priority in the asari population I hope that the stakeholders and us Rd care will have the courage to initiate bold change and I hope these stakeholders also reach out to palliative care I hope that we offer our assistance as well for the most at-risk patients and I hope these patients and families actually a Septon benefit from this care so that they're comfortable and supported towards the end of life so memento mori is is translated to remember you'll die and I know this sounds like kind of pessimistic but actually all my dialysis patients my palliative care patients and my father who passed away last November have all taught me to embrace life to to live it to the fullest or the time remaining because you just never know when you could die and that's one of the lessons I will leave here with I want to thank my fellowship classmates for helping me so much when my dad was in hospice and when he died I'm so indebted to you and I look so forward to seeing your many successes I'll be your biggest fan to my program directors Kathleen and Jane I am thanks for a septa me and I hope I've given to this program as much as it's given to me to all my attendings at both hospitals thanks for teaching this old dog new tricks thes old dog with long hair and too many tattoos and so all the interdisciplinary ins staff at both hospitals and social workers chaplains the nurse practitioners he all taught me so much thank you so much and to my my mentor Josh lakyn and kidney pal Ricky and Kate I look so forward to seeing you lead the revolution of palliative care and nephrology expects a lot of articles being published out of the Brigham with this and I look forward to collaborating rating with you in the future and most importantly I have to thank my wife she signed my permission slip to even be here in Boston so if it wasn't for her for her support I couldn't have done it and then of course lastly is my father who he taught me many lessons over the last year and I'll never forget them so I hope you enjoyed my presentation I hope it was fruitful and thank you very much [Applause] are there any questions here thank you so much it was wonderful you know I hold in my memory many of my patients that are in stage renal disease and dialysis and the challenges in the hospital where it appears that our discussions are about withdrawing care and in many of these situations there's a religious component as well as minorities people of color who you know don't have a necessarily a strong background of good care or access to good care and I'm wondering if you have any thoughts about those intersections yeah I mean that's a I've seen that you know a lot of us Rd patient's particular religious or those from minority backgrounds they struggle about the withdrawal concept I think there's many reasons for that one thing that I did as a nephrologist try to convey and I think it's the nephrologist job not the palliative care is to describe how the end of life could be off dialysis because there's a lot of fear I know Juliette and I in in clinic the other week had a patient in family just like this and you have to really express to them that we're gonna be there for you you will have hospice try to explain the concept but also the nephrologist has to also explain that when you become uremic we could palliate you with medicines but when you you start getting very uremic you just go to sleep you know you go into a nice coma and most of us would prefer to die in our sleep peacefully so when I mentioned and described it that way they tended to kind of relax a little bit and realize that you know the end of life might not be so scary after withdrawing from dialysis but again they want to hear from the nephrologist because that's the person been seen just like the oncologists with chemotherapy nephrologist is the one that's been seeing them for years and I think they would feel more comfortable hearing that from that person because they're the expert in the proven the procedure so that's kind of my experience at that it's a great question I have a comment and a question first of all thank you that was fabulous and a really great way to sort of synthesize so much information for us my comment is that maybe there is change generational change coming in that we used to have zero maybe one for ologist apply you are our first nephrology fellow here we have another one coming next year when I looked at the applications last year I think we had out of 150 applications maybe eight were from nephrology fellows so I feel like there must be that feeling coming and I'm hoping that they will be the change that's needed and so that brings my question about are you aware of groups either in palliative care or a nephrologist put forward yeah I've heard that in an academia there are some programs her in Seattle and in West Virginia the institutions there there are some the University of Pittsburgh actually is collaborating with DCI which is a dialysis company based out in Nashville with an ESCO and they actually presented data at HH p.m. in March that showed that they had a pilot study if some something that I described regarding the transition to hospice and in a pilot study so there is interest and this is a dialysis ESCO with academia and they also had a hospice agency also involved so I think it's it's there I think we just need to have more of it and also address the you know the barriers is particularly financial yeah I want to open it up for any questions at dana-farber or care dimensions thank you so much for this is really fantastic [Applause] [Applause]

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