Older adults with advanced chronic kidney disease and access to palliative care: Retrospective cohort study in primary care.

Objective: To describe the provision of primary and specialist palliative care for older adults with advanced chronic kidney disease (CKD).

Design: Population-based retrospective descriptive cohort study using electronic health records.

Setting: St Michael's Hospital Academic Family Health Team, including 5 clinics and an interdisciplinary home-based outreach team, in Toronto, Ont.

Participants: Older adults who are 65 years of age or older with advanced CKD and undergoing community-based nondialysis kidney care between April 1, 2012, and April 1, 2022, with at least 1 year of follow-up.

Main outcome measures: Prevalence of advance care planning, goals of care (GOC) discussions, access to specialized palliative care, frequency of hospitalizations, places of deaths, and mean survival time.

Results: The study included 47 older adults with advanced CKD who were not undergoing dialysis and receiving primary care. Sixty-eight percent were female (n=32), and the mean (SD) age was 81 (8) years. The mean (SD) number of comorbidities was 5 (2). Almost half of the patients (n=22) lived alone. Seventy percent of the cohort (n=33) had a documented substitute decision maker. Approximately one-third of the cohort (n=16) had GOC conversations involving prognosis, hospital transfer, place of death, and treatment goals. Forty-seven percent (n=22) accessed specialist palliative care during follow-up. Seventy-four percent (n=35) had 1 or more hospitalization. Thirty-two percent (n=8) died at home. The mean (SD) survival time was 2 (2) years.

Conclusion: A palliative approach to care including advance care planning and GOC conversations would be appropriate for older adults with advanced CKD given their high rates of comorbidities, hospitalizations, and mortality. Primary care providers might experience challenges facilitating conversations in this population, highlighting opportunities for enhanced training and point-of-care interventions, and facilitating access to specialist palliative care consultations when appropriate.