Caring Through the End:
Palliative Care Along the Continuum of CKD

Based on a symposium sponsored by the Mid-Atlantic Renal Coalition
(ESRD Network 5), December, 2004, Orlando, FL.

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Completing the Care Continuum
Ira Byock, MD
Hospice and Bereavement
Carla Braveman, RN, BSN, MEd, CHCE
Pain and Symptom Burden
Sara Davison, MD, MHSc, FRCPC
Panel Discussion: Overcoming Barriers to Palliative Care in the Dialysis Unit
Anthony Messana, Karin Anderson-Barrett, RN, JD, George Kelly, Lesley Dinwiddie, MSN, RN, FNP, CNN, Erica Perry, MSW
Incorporating Palliative Care into the Dialysis Unit
Michael Germain, MD
A Patient-Centered Approach to Advance Care Planning with Special Patient Populations
Elaine Colvin, RN, BSN, MEPD
Clinical Performance Measures for EOL
Richard Goldman, MD
Ethical and Legal Issues
Alvin Moss, MD
Advance Care Planning and CPR
Jean Holley, MD

Part 1

Keynote: Completing the Caring Continuum
  • Identify challenges presented by the current social context.
  • Specify ethical principles applicable to caring for patients at the end of life
  • Define palliative care and distinction with hospice care
  • Identify typical services provided by hospice and palliative care to patients and families.
  • Recognize that communication and advance care planning as essential elements of the continuum of care.
  • Describe an organized, on-going approach to symptom management
  • Review extra-ordinary symptom management, including palliative sedation and the critical distinction between such treatment and euthanasia
  • Recognize the nature of suffering associated with progressive illness and dying
  • Recognize the nature of opportunity during the phase of life termed “dying.”
  • Describe a life-cycle, developmental approach to supportive counseling and anticipatory-guidance for ESRD patients and their families that can assist with issues of life completion and closure
  • Identify leadership that clinicians and health care givers can provide society by caring in a manner that is not only competent and comprehensive, but also honors people in their dying

Hospice and Bereavement:

  • Review hospice and the Medicare Benefit
  • Describe the appropriate use of the Medicare Hospice Benefit with ESRD Patients
  • Describe the benefits to the family with Hospice bereavement services after the death

Pain and Symptom Burden:

  • Discuss the magnitude and scope of chronic pain and (0) symptoms in the ESRD population.
  • Discuss the impact of chronic pain in ESRD patients.
  • Discuss the potential barrier to adequate pain and symptom RX.
  • Outline potential strategies to enhance pain and symptom management
Part 2

Panel Discussion: Overcoming Barriers to Palliative Care in the Dialysis Unit
  • Identify the principal barriers to providing palliative care in dialysis units
  • Describe ways that units have overcome barriers
  • Present examples of how units have improved palliative care with interventions

Incorporating Palliative Care into the Dialysis Unit

  • Explain the importance of Palliative care at all stages of CKD.
  • Describe the importance of Advanced Care Planning, Goals Of Care.
  • Identify and treat common symptoms of CKD.
  • Express the importance of bereavement services.
  • Describe the role of hospice in CKD.
  • Identify the tools for developing a Palliative care program in the dialysis unit

Part 3

A Patient-Centered Approach to Advance Care Planning with Special Patient Populations

  • Discuss a pilot study using a patient-centered advance care planning interview.
  • Discuss implications of study and future research.

Advance Care Planning and CPR

  • Discuss the participants, purpose, and documents involved in advance care planning.
  • Discuss the barriers to advance care planning in dialysis units
  • Discuss the effectiveness of CPR in the dialysis population

Ethical and Legal Issues

  • Present the ethical concept of informed consent and the legal concept of patient self-determination
  • Discuss the ethical justifications for withholding and withdrawing dialysis.
  • Analyze cases of dialysis patients at the end of life in which decision-making posed a challenge.

Measuring Provider Performance of End-of-Life Care

  • Describe clinical performance measures relating to pain scales and quality of life indicators.
For Physicians, this learning activity (Parts 1, 2, and 3) is accredited for up to 7.9 CME credits by the School of Medicine, Virginia Commonwealth University, Medical College of Virginia Campus (VCU).

For nurses and dialysis technicians, this learning activity (Parts 1, 2, and 3) is accredited for up to 7.9 CE credit hours through the American Nephrology Nurses Association (ANNA).
Date of Release: May, 2005
CME Credit Eligible Through: May 1, 2006
CME Credit Eligible Through: August 1, 2006
Target Audiences: CME: Nephrologists, nephrology fellows, internists
CE: Nurses and dialysis technicians
Method of Participation: Listen to the talk, read the PubMed abstracts linked to data slides and talk references, complete the post-test and evaluation.

Physician Accreditation
The School of Medicine, Virginia Commonwealth University, Medical College of Virginia Campus (VCU), is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. This activity has been approved for AMA PRA Category 1 credit.

The School of Medicine, Virginia Commonwealth University, Medical College of Virginia Campus (VCU), designates this educational activity for a maximum of 7.9 hours (parts 1, 2, and 3) of Category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

Nursing Accreditation
The American Nephrology Nurses' Association (ANNA) is an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation (ANCC-COA). Provider approved by the California Board of Registered Nursing, Provider #CEP00910, for 7.9 contact hours (parts 1, 2, and 3).

The information presented is not intended to define a standard of care and should not be construed as doing so, nor should they be interpreted as prescribing an exclusive course of management.

Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation.

The views presented herein are those of the faculty and not necessarily those of the Mid-Atlantic Renal Coalition, the Medical College of Virginia, ANNA, or HDCN. This material is prepared based upon a review of multiple sources of information, but is not exhaustive of the subject matter. Therefore, healthcare professionals and other individuals should review and consider other publications and materials about the subject matter before relying solely upon the information contained within this material.

The Medical College of Virginia, ANNA, and HDCN have conflict of interest policies that requires course faculty to disclose any real or apparent commercial financial affiliations related to the content of their presentations/materials. It is not assumed that these financial interests or affiliations will have an adverse impact on faculty presentations; they are simply noted here to fully inform participants.

Please see individual speaker biographies (on the individual part 1, 2, and 3 pages) for disclosure statements.

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The Medical College of Virginia, ANNA, the Mid-Atlantic Renal Coalition, and HDCN do not recommend the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications and warnings.

To complete this educational activity, the user will need Windows or Macintosh operating software, a connection to the internet with a 28.8 kbps MODEM or better. The computer should have an audio card with speakers. An audio player, either the Windows Media Player from Microsoft or the Real Player from Real Media ( is required and either can be downloaded for free per instructions on the individual lecture pages. Acrobat Reader is required to print the CME or CE certificate, and this can be download free from Flash version 7.0 or higher is required to view the slide presentations, and can be downloaded from the links on the individual talk pages.

For any questions concerning this activity please send an email to or call HDCN at 630-325-3276.

See Pages for Part 1, 2, and 3 for Faculty List
This Mid-Atlantic Renal Coalition Educational Conference was originaly presented on December 1-3, 2004 in Orlando, Florida.

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