Palliative Care Disincentives in CKD: Changing Policy to Improve CKD Care

Am J Kidney Dis. 2018 Jun;71(6):866-873. doi: 10.1053/j.ajkd.2017.12.017. Epub 2018 Mar 3.


The dominant health delivery model for advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States, which focuses on provision of dialysis, is ill-equipped to address many of the needs of seriously ill patients. Although palliative care may address some of these gaps in care, its integration into advanced CKD care has been suboptimal due to several health system barriers. These barriers include uneven access to specialty palliative care services, underdeveloped models of care for seriously ill patients with advanced CKD, and misaligned policy incentives. This article reviews policies that affect the delivery of palliative care for this population, discusses reforms that could address disincentives to palliative care, identifies quality measurement issues for palliative care for individuals with advanced CKD and ESRD, and considers potential pitfalls in the implementation of new models of integrated palliative care. Reforming health care delivery in ways that remove policy disincentives to palliative care for patients with advanced CKD and ESRD will fill a critical gap in care.

Keywords: Chronic kidney disease (CKD); advance care planning; dialysis; end-stage renal disease (ESRD); goals of care; health policy; palliative care; patient-centered care; quality of life.

Publication types

  • Research Support, N.I.H., Extramural
  • Review

MeSH terms

  • Advance Care Planning / organization & administration
  • Delivery of Health Care / organization & administration*
  • Female
  • Health Policy
  • Hospice Care / organization & administration
  • Humans
  • Kidney Failure, Chronic / diagnosis
  • Kidney Failure, Chronic / epidemiology
  • Kidney Failure, Chronic / therapy*
  • Male
  • Palliative Care / organization & administration*
  • Policy Making
  • Quality Improvement*
  • Renal Dialysis / adverse effects
  • Renal Dialysis / methods*
  • Renal Insufficiency, Chronic / diagnosis
  • Renal Insufficiency, Chronic / epidemiology
  • Renal Insufficiency, Chronic / therapy*
  • Treatment Outcome
  • United States