Greater Awareness on Conservative Treatment as a Viable Option for Elderly Patients with End-Stage Renal Disease

SINGAPORE, 19 September 2018 - Most people expect dialysis, be it haemodialysis (HD) or peritoneal dialysis (PD), to be a common treatment for patients with End-Stage Renal Disease (ESRD) or kidney failure. However, not many know that the symptoms of kidney failure can also be managed through a combination of dietary control and medication, which is a type of non-invasive treatment known as conservative management.

With the support of Temasek Foundation Innovates through its SMF Research Grant Programme, researchers from Duke-NUS’ Lien Centre for Palliative Care (LCPC) and Singapore General Hospital (SGH) conducted a study to understand the attitudes of elderly renal patients and their care givers towards dialysis and conservative treatment. The study on patients with various stages of kidney disease found that 40 per cent of patients and 46 per cent of caregivers were unaware of the conservative management as a possible option.

Findings suggest that among the patients and caregivers who were aware of conservative management, 50 per cent were willing to consider it as an option if they were aware of its benefits such as life expectancy, quality of life and costs. The study also found that half of the renal patients tend to depend on their physicians for opinions and recommendations regarding their care plan.

Lead author of the study and Director of Lien Centre for Palliative Care, Dr Eric Finkelstein, said, “Patients need to have adequate information and understanding before deciding on whether to opt for dialysis or conservative management. More efforts can be put into educating patients who have chronic kidney disease about haemodialysis, peritoneal dialysis and conservative management as well as making resources available at various care points, for example, dialysis centres, outpatient clinics and polyclinics.”

According to Dr Sheryl Gan, Consultant, Department of Renal Medicine, SGH, who is one of the authors for the study, “Patients are usually counseled on their condition and management through lifestyle changes and medications by our care team during the early stages of their chronic kidney disease. Doctors only start the discussions on treatment options with considerations for patients’ preferences when the need for dialysis arises.”

Conservative treatment is most relevant for elderly patients with multiple comorbidities who may have passed the stages of benefiting from dialysis. If an ESRD elderly patient decides to opt for this treatment, the care team continues with medications and lifestyle changes to treat the complications of chronic kidney disease.

The palliative team is brought in when the patient starts developing symptoms such as breathlessness and nausea – signs that medications are no longer effective. Towards the end of the patient’s life, a hospice team helps to care for the patient and to minimise hospital visits to allow the patient more time at home with his family.

Currently, discussions on dialysis and conservative management are brought up only when renal patients have reached stage 4 of their chronic kidney disease. Stage 5, being the end stage, is the time when dialysis or renal transplantation is needed to stay alive.

Dialysis is usually a long-term therapy with the continued need for medications, clinic appointments and associated procedures. This may lead to a reduction in the patient’s reported quality of life. While younger ESRD patients are likely to enjoy survival benefits from dialysis, it may not be the same for the ESRD elderly with other illnesses like diabetes or heart disease.

The survey was done at SGH in 2015 to understand the attitudes of 160 renal patients and their caregivers towards dialysis and conservative management. It also looked into factors that could influence the demand for dialysis. These patients, who are on average 74 years old, had stage 3B to 5 of chronic kidney disease and might not have undergone counselling on dialysis and conservative treatment yet. The most common co-morbidities they had were diabetes and heart disease.

Chairman of Temasek Foundation Innovates, Professor Leo Tan, said, “We recognise that palliative care has become even more vital today, due to our rapidly ageing population. We all want to have good quality of life, but how to achieve this in the face of a life limiting illness may not be so clear. We hope that our support for studies such as this will create more awareness of different treatment options, new findings and innovations so that Singaporeans can make better informed decisions on end-of-life care.”

To facilitate better decision-making for patients, LCPC and SGH have embarked on another study to better understand how communication messages and materials can be tailored to improve the patient autonomy of elderly ESRD patients. This is to ensure that they can receive treatments that are consistent with their preferences.

 

For media enquiries, please contact Ms. Tam Shu Er, SGH Communications, or Ms. Naseema Banu, Duke-NUS Communications.