Finding a pathway to better palliative care for kidney patients

For as long as she's been a physician, Sara Davison has been passionate about improving the lives of her patients. A trained nephrologist and professor in the University of Alberta's Department of Medicine, she says she's driven to make a lasting difference in their care.

"I have always gravitated towards establishing relationships with patients. Very early on I saw that the issues where my patients struggled the most and which caused them the most distress were around end-of-life care."

"I started my career with a passion for this issue, saying I was going to change this."

Today, thanks in part to Davison's direct efforts, her goal is being achieved.

Davison is the lead author of a report that provides the framework for developing new international guidelines on kidney palliative care. The report, released in the April 29 edition of the journal Kidney International, identifies key areas in which to improve palliative care for patients with advanced chronic kidney disease, a condition characterized by gradual loss of kidney function over time.

Priorities highlighted in the report include improving pain and symptom management, proper prognostication, shared decision-making and advanced care planning between physician and patient, decision-making regarding the appropriate start or withdrawal of dialysis, and implementation of conservative care—a treatment option that provides quality care and comfort to patients while allowing the disease to run its natural course, without dialysis.

"The default clinical pathway is that patients reach end-stage kidney disease and then start dialysis. But some older patients, or those with a lot of comorbidity or who are very frail, don't always do well on dialysis," explains Davison. "For some patients, dialysis may actually worsen their quality of life and survival."

"We're now developing conservative pathways of care for patients who are unlikely to benefit from dialysis, where we focus on rehabilitation where possible, preservation of quality of life and physical function, good crisis management and quality end-of-life care. These patients do better—and may actually live longer—but don't have dialysis. It's a win-win."

Davison also says current access to palliative care needs rethinking for patients with advanced chronic kidney disease. For example, right now in Alberta palliative care access is often limited to the last months of a patient's life—a less than ideal system for patients whose severe conditions and palliative care needs can extend for years before they die.

"It's about patient-centred care," says Davison. "Our focus needs to include clinically relevant outcomes from patients' perspectives. What do they need to live a life worth living?"

Along with helping create new international guidelines for kidney palliative care, Davison is also working on national guidelines to be released in early 2016.

Davison's efforts have also recently been recognized by her peers. This spring she was named the 2015 Edmonton Zone Medical Association Researcher of the Year for her work on palliative care. It's an honour she says goes back to her very first priority—the patients.

"I think what was most pleasing is that it allows the voice of my patients to be heard. My research agenda is built around patients' priorities, so in getting this award, I feel these patient priorities are being recognized."