$9m pilot initiative to integrate palliative care into chronic kidney disease treatment

SINGAPORE – The National Kidney Foundation (NKF) and three major public hospitals here are providing palliative care to patients with advanced chronic kidney disease (CKD), under a $9 million, four-year pilot programme supported by the Lien Foundation.

Called Renalssance, the initiative seeks to challenge the “dialysis by default” mindset by integrating palliative care into the treatment journey much earlier, relieving patients’ symptoms, pain and stress alongside active medical care.

The hospitals – National University Hospital (NUH), Singapore General Hospital (SGH) and Tan Tock Seng Hospital (TTSH) – each represent one of the three healthcare clusters that oversee care across Singapore.

Renalssance is expected to benefit more than 5,260 patients over four years – 1,500 from each hospital, and 760 from NKF.

Taking palliative support upstream ensures that CKD patients also have the option of choosing not to do dialysis but to get palliative care, the five partners said in a joint release on June 1. This allows for care plans that address not only the patients’ medical needs, but also their functional, emotional and psychosocial well-being.

Many people often assume dialysis is the default treatment for kidney failure because it is widely recognised and commonly presented as the only alternative to a transplant.

However, it is not always the best choice. For frail seniors and those with severe medical conditions such as cancer and cardiovascular disease, it is often less effective in extending lifespan. They can also suffer from nausea, muscle cramps, headaches and other issues, said Kwek Jia Liang, a senior consultant at SGH’s renal medicine department.

International studies have shown that for patients who are aged 80 and above and have multiple illnesses, starting dialysis may extend their life by only about two years. Much of this remaining time, however, is spent in healthcare settings due to dialysis complications, he said.

CKD affects 14 per cent of Singaporeans today – higher than the global average of 10 per cent. This disease is projected to affect one in four by 2035.

Previously, palliative care would be offered towards the end of life, if it was made available at all. Renalssance hopes to change that. It involves training nurses to proactively identify and counsel CKD patients earlier on their options, before they reach end-stage kidney failure.

At SGH, for instance, two nurses have been having palliative care conversations with patients.

“We identify patients who are going to reach kidney failure in a year or two. Even though they are still feeling pretty okay, that’s when we should start talking to them about all the options they have,” Kwek told ST.

However, it can be a challenge. “There are patients asking us, ‘Why am I seeing you?’, even though their kidney function is at less than 20 per cent,” he said.

This occurs when the patient is in the fourth of the five stages of CKD. They may start to have sleeping problems and feel weaker, but they tend to view these as a part of ageing rather than signs of a progressive illness, he said.

At some point, patients at this stage of kidney disease and their caregivers will have to think about whether or not to go for dialysis.

With Renalssance, patients with advanced CKD at the three hospitals will eventually be offered early palliative care, regardless of whether they opt for dialysis or non-dialysis care.

This involves providing treatments that relieve symptoms and suffering, identifying and honouring patients’ wishes, supporting caregivers, and striking a balance between medical intervention and quality of life.

For patients who opt for dialysis, palliative care will be provided concurrently with their dialysis treatment.

At NKF dialysis centres, patients who have commenced dialysis will now be monitored more closely for their overall well-being.

Those who choose non-dialysis care will be referred to suitable community care providers such as active ageing centres, home care services or hospices, depending on their needs. They will continue to be overseen by their primary nephrologist at the hospital, who will drive each patient’s treatment plans. They can opt for dialysis, should they change their minds.