Four plus forty-four: hours to modify, theirs to enjoy.

The evolution of dialysis care over the last 60 years is noteworthy. From the earliest days, when Kolff used the drumdialyzer,throughmanyiterativechanges,discoveries, and developments, dialysis can now be used in multiple settings under numerous adverse circumstances for prolonged periods of time. However, with these innovations and successes come new and perhaps, more challenging questions around appropriateness, futility, and howwe as clinicians can measure benefit. Many clinicians will recall times when, in hindsight, it was unclear whether the patient benefitted from dialysis treatments, whereas somemay recall situationswhere, perhaps, the initiation of dialysis played a role in what resulted in a difficult or prolonged dying process. As the evidence against dialysis treatment is growing, so are the questions around appropriateness in certain subgroups (1–5). Increasingly, studies are showing, particularly in older individuals with a high burden of comorbidity, that patients can do equally well with or without dialysis treatments (6–11). In several centers, nondialysis (or conservative care) pathways are being incorporated into clinics, and patients are being educated about their right to choose to not include dialysis in their renal care plan. In this issue of CJASN, Brown et al. (12) further add to the data supporting nondialytic pathways. Brown et al. (12) present data that show that symptoms can be effectively controlled and that patients experience similar quality of life with or without dialysis. In their program, patients who opt for a nondialytic care plan are seen by both the nephrologist and a palliative care team (12). The palliative care team members actively elicit and manage physical symptoms and existential issues and help with advance care planning, whereas the nephrology team continues to work at preserving residual renal function, anemia management, and fluid balance. At the 6and 12-month marks, 42% and 57% of patients, respectively, in the collaborative program reported reduced symptomburden,which one assumes is despite progression of their renal disease. The option to forgo dialysis as part of the renal care plan is increasingly being offered to patients and families, and similar clinics are slowly being established worldwide.Studies fromtheUnitedKingdom,Australia, and Canada suggest that around 15%–20% of those advised to consider a conservative or nondialytic route would actually opt out of dialysis care (6,7,9–11). A few will change their mind over time, but most do not, and families report a satisfactory or good dying process. Although the proportion of patients opting out of dialysis care varies with patient demographics, geographic location, and cultural environment, one would expect these numbers to continue to stabilize over time as we improve prognostication and more and more clinicians receive formal training in shared decision-making. Prognostic calculators are helpful; however, they are best used to initiate frank and open discussions about the expectations that patients and families have rather than guide modality choices (13,14). Not all patients starting dialysis with a high score do poorly. Around 25% will survive past the first year, and of those, many will report quality of life scores marginally higher than their younger counterparts. It is with these people in mind that the study by Brown et al. (12) becomes important. Their data should remind us that both those patients opting for dialysis and those patients opting for a nondialytic care pathway have a high symptom burden (12). Our patients look to us for their medical care during not only the 4-hour dialysis treatments but also, the intervening 44 hours! Symptoms, such as difficulty sleeping; dry or itchy skin; anxiety, sadness, or depression; andpainand restless legs, are common (15–17), and yet, they are often overlooked and undertreated. Brown et al. (12) show that palliative care teams can reduce the symptom burden. So why not shift our thinking? Rather than restricting symptom management to those who elect to forgo dialysis, should we not be developingpolicies that helpus extend symptomcare to all patientswith renal disease? Shouldwenotmore actively seek to help those for whom dialysis is the final destination (18,19)? Neither the concept of a collaborative program nor the concept of introducingpalliative care early in adisease course is novel. In 2010, Temel et al. (20) randomized patients newly diagnosedwithmetastatic nonsmall cell cancer to either collaborative care with an oncologist and a palliative care team or themore traditional oncologist-led care. The data from the study by Temel et al. (20) suggest that addressing thephysical andpsychological symptoms of patients can help patients manage what are otherwise unpleasant and burdensome treatment interventions. Although from a small single-centered study open to biases becauseof itsnonblindeddesign, theirdata suggested that the use of collaborative care from an early stage resulted in improved patient-reported outcomes, reduced use of inappropriate medical interventions, and possibly, extended survival. Many now advocate for earlier use of palliative services in oncology (21). Division of Nephrology, Faculty of Medicine, University Health Network, Toronto, Ontario, Canada