Why Palliative Care Belongs in the Room Before Life-Prolonging Measures Begin - An Opinion Piece
In cardiology, national guidelines already recommend that every patient receiving a left ventricular assist device (LVAD) also receive a palliative care consult. The rationale is both evidence-based and deeply humane: when a person is about to commit to a complex, life-prolonging technology, they deserve the dignity of informed, values-based decision-making.
So why are we not doing the same for dialysis?
Dialysis: A Decision, Not a Default
Dialysis is not a neutral intervention. It is a life-prolonging machine, often framed as the “next step” rather than a major medical decision. Many patients are initiated without understanding what dialysis truly entails—the time commitment, the physical burden, the impact on independence, and what it means for the final phase of life.
Integrating palliative care before dialysis begins could transform how patients and families approach this life-altering therapy. Here’s what we gain:
1. Advance Care Planning
Starting dialysis presents a natural and necessary moment to explore goals of care. What does the patient value most? How do they define quality of life? What are their wishes if their condition declines? These are not questions we should be asking months or years into treatment—they belong at the outset.
2. Realistic Expectations
Palliative care helps clarify that while dialysis can extend life, it does not halt the progression of chronic kidney disease. For older patients, those with multiple comorbidities, or individuals nearing end of life, understanding the limitations and potential complications of dialysis leads to better decisions and fewer regrets.
3. Laying the Foundation for Future Support
Dialysis is rarely the final stop. Many patients on dialysis will eventually require palliative or hospice care. A palliative consult early on builds trust, opens the door to ongoing support, and makes transitions feel less abrupt or emotionally charged.
Beyond Dialysis: Other Life-Prolonging Measures That Deserve Palliative Partnership
Dialysis is just one of many interventions where palliative care belongs upstream. Other examples include:
- ECMO (Extracorporeal Membrane Oxygenation): Reserved for the most critically ill, ECMO often involves long ICU stays with uncertain outcomes. Palliative care can ease family distress, clarify prognosis, and support ethically challenging decisions.
- Tracheostomy and Long-Term Ventilation: These interventions fundamentally change a patient's daily life. Palliative consults ensure informed consent, guide expectations, and promote dignity through transitions.
- Feeding Tubes in Advanced Dementia or Neurologic Illness: Commonly placed by default, these tubes may not improve survival or comfort. Palliative teams help families navigate these gray zones with clarity and compassion.
- ICDs and CRT-Ds (Implantable Defibrillators): Devices meant to prevent sudden death can lead to painful shocks at life’s end. Palliative care offers critical guidance on deactivation planning.
- CAR-T and Bone Marrow Transplant: These therapies hold curative potential, but with intense risks. Palliative integration ensures that hope is tempered with honesty and holistic support.
- Mechanical Circulatory Support (e.g., Impella, IABP): While often lifesaving, temporary mechanical supports can lead to prolonged, non-recoverable critical illness. Palliative care can help patients and clinicians navigate when to continue—or not.
Policy & Systems Change: Embedding Palliative as Standard of Care
To make these changes real, we must move from anecdote to action. National guidelines should reflect what frontline clinicians already know: early palliative care improves outcomes, reduces suffering, and supports better resource stewardship.
Here’s what we need:
- Clinical Guidelines: Just as the LVAD guidelines mandate palliative consultation, nephrology, pulmonology, oncology, and critical care societies should incorporate palliative care into protocols before life-prolonging therapies are initiated.
- Payer Incentives: Value-based care organizations and Medicare Advantage plans should reimburse and encourage early palliative consults before high-cost interventions – are initiated.
- Hospital Policy: Health systems can implement internal triggers: for example, a palliative care consult before tracheostomy, PEG tube placement, or initiation of home dialysis.
- Medical Education: Training programs must equip future clinicians with the mindset and skills to see palliative care not as an end-of-the-road option, but as a partner throughout serious illness care. Mandating a full rotation in our specialty in training is necessary to train all clinicians in communication skills and knowledge of our services.
- Increased Palliative Care Work Force: The need for more Palliative Care specialists is outpacing the demand. Many solutions may exist, including reducing the stigma of end-of-life care and early and often introduction of the specialty to trainees- nursing, PAs, and physicians.
The Bottom Line
Palliative care is not about stopping treatment. It’s about ensuring that the treatments we offer align with what patients want, need, and understand. When we integrate palliative care before life-prolonging measures, we rewrite the narrative—not just for patients, but for the entire system.
It’s time we stop waiting until the last chapter to involve palliative care. Let’s bring it in early—so that the chapters we write together are ones filled with intention, clarity, and peace.
Citations/Further Reading
Szeto DA, Whitney RL, Alcantara DE. Standardizing Initial Inpatient Palliative Care Consultations for Patients Receiving Left Ventricular Assist Devices at a Large Urban Hospital. J Hosp Palliat Nurs. 2025 Feb 1;27(1):E43-E50. doi: 10.1097/NJH.0000000000001082. Epub 2024 Nov 28. PMID: 39607337.
Salomon S, Frankel H, Chuang E, Eti S, Selwyn P. Implementing Routine Palliative Care Consultation Before LVAD Implantation: A Single Center Experience. J Pain Symptom Manage. 2018;55(6):1350–1355. ()
https://www.capc.org/blog/rethinking-kidney-care-the-role-of-conservative-kidney-management/
