Management of Renal failure without Dialysis: is there a magic trick?

C Holman, M Higginbotham, C ones

York Hospital

Problem: Before May 2003 Renal Consultants managed and coordinated the care of patients with ESRF who were not having dialysis, without input from the Renal MDT. Very small numbers of these patients were referred to the Renal Social Worker and/or the PD nurses to visit the patient and their families at home. The Renal Team were seeing many elderly patients” making a choice” to start dialysis and then struggle to manage. The Renal Registry 2003 showed that we had the second oldest dialysis population in England.

Purpose: To create a coordinated and planned treatment approach to the management of patients without dialysis.

Design: A small group was set up including Macmillan Nurses, Hospital Palliative Care team, District Nurses, Renal Social Worker, Renal Consultant and newly appointed Pre-dialysis Sister, to look at how we could manage this group of patients. This group met three times.

Method: The group formulated:

· A conservative care pathway

· Written information for patients and their families to be included in our ‘Living With Kidney Failure’ guide

· An information leaflet on symptom management for health care professionals, e.g. GP’s, District Nurses

Throughout the whole process all professionals from the Renal MDT were involved and contributed to formulating the pathway and information sheets.

A further review meeting was held in September 2004. It became apparent that the Palliative Care Teams felt that

the Renal Team are the experts in managing these patients. We therefore planned to undertake teaching sessions with the Macmillan nurses and the local Hospice regarding the management of patients with renal failure.

Conclusion: All patient’s approaching end-stage renal failure are now given information about all treatment options, including the choice of treatment without dialysis. We now have a coordinated and planned treatment approach for patient’s choosing not to dialyse, and we continue to develop and strengthen links with Primary Care colleagues and the Palliative Care Teams.

Relevance: The care and management of this group of patients and their families is a complex area and raises ethical, moral, legal and emotional dilemmas for all involved. There is the need for the renal team to work together with our colleagues in the hospital and community to offer ‘’good enough’’ care to the patient and their family.

The development of this service has implications for the workforce, in terms of increased workload and the need for development of appropriate skills. There is no magic. What is required is the integration of social, medical and nursing care, and a multi-skilled team of health and social professionals working together to deliver this service.