FEATURE

It Takes a Team: Sharing the Caring

Dr. Lewis Cohen has been awarded a two-year grant from the National Institutes of Health for a groundbreaking hospice intervention study for older patients with end stage renal disease (ESRD).

Fortunately, Dr. Cohen doesn’t believe the baseball maxim, “Three strikes and you’re out!” After NIH rejected his third proposal, he remained undeterred, even though “each of the proposals was the most difficult I had written in my life.” So, with a team of research methodologists and biostatisticians from Baystate and Tufts-New England Medical Center, he submitted a fourth proposal, and this time he “hit one out of the park.

Cohen and his colleague Dr. Michael Germain coined the phrase Renal Palliative Care more than fifteen years ago. Considered pioneers in the field, in the 1990’s they were the first to report research on the psychological, physical and social aspects of end-of-life decisions made by patients with ESRD. Results from a more recent Robert Wood Johnson Foundation-funded demonstration project to integrate the latest advances in palliative care for ESRD patients prompted Cohen’s current project.

Hospice: Just what the Doctor Should Order?
The RWJ project revealed that medical staff “only knew so much about end-of-life issues,” and in fact seemed to have an inaccurate perception of the prognosis and morbidity of patients on dialysis. Alternatively, hospice providers had experience talking about dying, advance care planning, and alleviating pain and suffering. Approximately 75,000 patients with ESRD will die this year, three-quarters of them will be over 65, and many will experience painful deaths outside their homes. But patients with ERSD are infrequently referred to hospice - no more than 13% receive hospice care as compared to 60% of those dying of cancer. In his current project, Cohen’s aim is to increase the use of hospice care by older patients with ESRD.

Patients and Staff Need Education to Ease Access
Cohen’s project will study the impact of a Renal Supportive Care Team consisting of community hospice and dialysis center staff. The team will meet with hemodialysis patients and families to discuss hospice care, and with the staff of hospitals and nursing homes to facilitate hospice referrals. Evidence generated from this study could create a platform for nephrology, psychiatry and hospice service organizations to collectively lobby federal healthcare agencies to amend their criteria for providing hospice services to ESRD patients.

The results could also provide the basis for a future study. Cohen is planning to go to bat once again – this time with a proposal for an ambitious multi-center investigation to examine whether increased use of hospice care improves quality of life and end-of-life care for ESRD patients.

* The National Kidney Foundation terms this stage 5 CKD (Chronic Kidney Disease.)

Further Reading:
Cohen LM, Moss AH, Weisbord SD, Germain MJ. Renal Palliative Care. Journal of Palliative Medicine 2006;9:977-992.

Arnold RM, Solomon L. Editorial: Renal Palliative Care: Supporting Our Colleagues, Patients and Family. Journal of Palliative Medicine 2006;9:975-976.