Nephrol Dial Transplant (2003) 18: 2688
© 2003 European Renal Association-European Dialysis and Transplant Association
Letter
Assessment of severity of illness in end-stage renal disease patients: need for multi-disciplinary effort
Department of Internal Medicine Mayo Clinic Rochester, USA Email: ghosh.amit{at}mayo.edu
Sir,
Dr Weisbord and colleagues [1] ought to be congratulated in their attempt to validate the severity of illness in patients with end-stage renal disease (ESRD). A perusal of the symptoms listed in table 2 [1] depicts a range of complaints which may be easily overlooked, if not actively sought for, by the medical personnel. The usual guidelines for adequacy for dialysis and reliance on surrogate markers (creatinine, albumin, haemoglobin, etc.), may fall short in out attempt to understand the symptom load of the patients, as is demonstrated in the current paper.
In spite of annual mortality of 24% in this population, which far exceeds that of several malignancies [2], there lies an inherent inertia among both physicians and patients to communicate and understand the gravity of the situation. There may be several reasons for this behaviour, including, inability to adequately address care of symptoms, lack of training in palliative care, over-reliance on surrogate markers, lack of time, increasing confidence on the ability of dialysis to prolong life, to name but a few.
A rather simple approach to assess the severity of illness would be to address the patients’ response to four elements of severity, namely, distress, disability, seriousness and urgency [3]. Distress deals with symptoms which make the patient feel unwell, disability deals with interference with functions, seriousness indicates issues which are a threat to life and urgency deals with the time construct for an intervention. A quick survey of these four elements could cover a lot of ground covered in the HRQoL questionnaire indicated in the current study.
The complexity of care involved in the management of patients with ESRD warrants a multi-disciplinary effort involving the nephrologist, the social worker, the dietician and palliative care, as in the current study. The high qualitative appreciation for palliative intervention by both physicians and patients in the current study (76% and 68%, respectively), in the absence of any demonstrable reduction in the number of symptoms, indicates that in an evidence-based management of assessing the effectiveness of intervention, a sum total of both qualitative and quantitative analysis is indicated. Over-reliance only on quantitative measures would tend to ignore the complex non-linear trends of symptoms which accompany chronic medical disease [4]. The current article challenges us to continuously revisit our current treatment strategies when it comes to taking care of patients with ESRD.
Conflict of interest statement. None declared.
References
- Weisbord SD, Carmodt SS, Bruns FJ et al. Symptom burden, quality of life, advance care planning and the potential value of palliative care in severely ill haemodialysis patients. Nephrol Dial Transplant 2003; 18: 1345–1352
[Abstract/Free Full Text] - US Renal Data System. USRDS 2001 Annual Data Report. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2001
- Davidoff F. Severity. The missing link between disease and illness. In: Davidoff F, ed. Who Has Seen a Blood Sugar? Reflection on Medical Education. ACP, Philadelphia, PA, 1996; 146–151
- Plsek PE. Greenhalgh T. Complexity science: the challenge of complexity in health care. Br Med J 2001; 323: 625–628
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