The question of receiving kidney dialysis while under hospice care is common for patients and families navigating end-stage kidney disease (ESRD). Hospice care is a specialized approach focused on providing comfort, managing symptoms, and ensuring quality of life for individuals with a terminal illness, typically when a physician estimates a life expectancy of six months or less. Dialysis is a medical procedure that artificially filters the blood to remove waste products and excess fluid when the kidneys fail completely. This article explores the logistical, financial, and medical realities of combining these two fundamentally different forms of care.
Understanding the Goals of Hospice and Dialysis
Hospice and traditional kidney dialysis are founded on opposing philosophical goals for patient care. The primary objective of standard, maintenance dialysis is to sustain life and manage the chronic condition of ESRD indefinitely, often viewed as a life-extending treatment. Patients undergoing this regular treatment hope to continue living for years, despite their underlying kidney failure.
Hospice care is predicated on the idea that the underlying disease has progressed to a point where curative treatments are no longer effective or desired. The focus shifts entirely to palliative care, aiming to relieve physical and emotional suffering without attempting to reverse the disease process. This fundamental difference in treatment intent creates a significant conflict when a patient wishes to pursue both services simultaneously.
To qualify for the Medicare Hospice Benefit, a patient must have a physician’s certification that the illness is terminal with an expected prognosis of six months or less. Since standard dialysis is designed to prolong life, its continuation directly contradicts the core requirement of the hospice benefit when ESRD is the primary terminal diagnosis. This regulatory hurdle is the main reason why concurrent care is generally not permitted under standard policy.
The Regulatory Conflict Preventing Concurrent Care
The primary barrier to receiving both services simultaneously stems from the structure of the Medicare Hospice Benefit (MHB). When a patient elects hospice, they agree to discontinue treatments intended to cure the terminal illness. Since dialysis for ESRD is classified as a life-sustaining treatment, receiving both under the same benefit structure is generally prohibited.
The core issue is financial coverage. The hospice agency receives a fixed per diem rate from Medicare to cover all services related to the terminal diagnosis. Dialysis treatments are exceptionally expensive, and the standard daily rate is insufficient to cover the cost of three-times-weekly dialysis. This financial disincentive means most hospice organizations cannot afford to accept patients who continue full-schedule dialysis for their terminal diagnosis of ESRD.
This policy forces patients with ESRD to choose between continuing life-prolonging dialysis or discontinuing it to enroll in hospice for comfort care. Many patients enroll only after stopping dialysis, leading to a very short length of stay, often just a few days. The regulation essentially links hospice enrollment with the discontinuation of the life-sustaining treatment for kidney failure.
Scenarios Where Palliative Kidney Care is Provided
While the standard regulatory framework often prevents concurrent care, specific scenarios allow patients to receive comfort-focused kidney care while enrolled in hospice. One notable exception is if the patient’s terminal diagnosis is something other than ESRD, such as advanced cancer or heart failure. In this situation, the patient can receive hospice care for the non-renal illness while Medicare continues to cover full dialysis treatments, as the dialysis is not related to the certified terminal diagnosis.
Another alternative is a modified approach known as “palliative dialysis.” This is a reduced or altered schedule of treatment aimed purely at managing symptoms rather than extending life. This modified schedule might involve a single, shorter treatment per week to relieve uncomfortable symptoms like severe fluid overload, shortness of breath, or intractable nausea. Palliative dialysis is sometimes provided through specific pilot programs or alternative payers, such as the Veterans Health Administration (VA), which has more flexible criteria for concurrent care.
These concurrent hospice and dialysis programs focus on quality of life and symptom control while allowing a reduced frequency of dialysis for comfort. This approach is often reserved for patients who wish to continue some form of dialysis alongside hospice services. It has been shown to increase the median length of hospice stay compared to patients who stop dialysis completely before enrollment.
Comfort Care When Dialysis Treatment Ceases
When a patient decides to withdraw from dialysis, the hospice team provides comprehensive comfort care focused on managing the symptoms of kidney failure. Without the blood-filtering process, waste products and toxins accumulate rapidly in the bloodstream, a condition known as uremia. This uremic state typically leads to symptoms like confusion, agitation, and somnolence.
Fluid overload is another immediate concern, which can cause severe shortness of breath (dyspnea), swelling (edema), and joint stiffness. The hospice care plan uses medications such as diuretics to manage fluid and opioids to relieve pain and air hunger. Hospice teams prioritize patient comfort and use specialized symptom management protocols for renal failure.
Specific pharmacological choices are made to avoid drug accumulation in the absence of functioning kidneys. For example, hydromorphone is often preferred over morphine for pain relief because its metabolites are less likely to accumulate and cause adverse effects. The hospice team also manages nausea, itching (pruritus), and anxiety using carefully adjusted medications like ondansetron or low doses of benzodiazepines. For an anuric patient, death typically occurs within 7 to 10 days after stopping dialysis, making prompt symptom management crucial.