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Post CCT Fellowship in Palliative Renal Medicine
Background and case of need
With the increasing number of patients on renal replacement therapy (RRT),
the treatment increasingly caters to a more elderly, co-morbid population. In
2010, the median age of a patient starting RRT in the UK was 64.9 and
peripheral vascular diseases and ischaemic heart disease affect between 15
and 29% of those aged 65-74. The unadjusted one year survival for a patient
on RRT is 83.8%; however the five year survival for a patient starting dialysis
aged over 65 is 29%1. Of the four most common cancers (prostate, lung,
colorectal and breast) only lung cancer compares less favourably2. In
addition, the symptom burden for a patient on dialysis is similar to the profile
of a patient with metastatic cancer3.
Several key documents have highlighted the need to tailor care more
appropriately towards the supportive needs of renal patients4-7.
Several centres across the UK have established that offering conservative
kidney management as a positive choice results in a significant uptake,
particularly amongst patients who are least likely to do well on dialysis such
as those over 79 years with multiple co-morbidities and poor performance
status 8,9.
Apart from the high tariff for dialysis the personal cost for patients is significant
with haemodialysis patients likely to spend half of their lives in hospital and
6% of patients dying in the first three months of dialysis1.
In order to provide a high quality service to meet the complex needs of this
growing group of patients, physicians need a broad range of knowledge and
skills spanning nephrology and palliative medicine. The anxieties of doctors
prescribing in renal failure is well documented but so too is the poor
management of symptoms such as pain by nephrologists. At present,
nephrology training covers palliative care to a very basic level, and palliative
medicine training covers some basic aspects of nephrology. However, neither
curriculum provides the detailed knowledge and skills required. A palliative
renal physician would enhance the care of these patients, bridging the gap
between the specialties and should be attractive to employers.
We propose a novel approach to a post CCT Fellowship that could take a
specialist with a CCT in either renal or palliative medicine and provide the
necessary training and experience to deliver high quality palliative renal
medicine. Two outline programmes would be made available to cater for
physicians from each “host” specialty, modified to suit individual needs. The
fellowship would be completed in 12 months.
Aims of the Post-CCT Fellowship in Palliative Renal Medicine
1. To develop physicians with the knowledge, skills and behaviours to
manage patients with stage 4-5 CKD and complex co-morbidities
2. To routinely provide patients with an informed choice about high quality
palliative renal care in place of RRT to enable shared decision-making
Post CCT Fellowship in Palliative Renal Medicine
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3. To provide patients with high quality symptom management whilst
receiving RRT
4. To provide patients with ongoing choice about when/whether to stop
RRT when it becomes too burdensome to continue and to manage the
transition to end-of-life care on stopping RRT
5. To act as a resource for teaching/training nephrology and palliative
care colleagues on palliative renal medicine
6. To act as a resource in managing and planning renal palliative care
services.
Organisation and supervision
Each Fellow will have supervision from both a palliative and renal medicine
consultant who will act as educational guides. The lead guide will be agreed
at the outset of the programme. It is expected that the Fellow will meet with
their guides at the beginning of the Fellowship to set a formal personal
development plan (PDP). This will be reviewed at the mid-point and end of the
Fellowship.
Common elements of the Fellowship programme that apply to CCT
holders in renal and palliative medicine
Leadership
Fellows will be expected to demonstrate that they have negotiated learning
experiences to improve their effectiveness in leadership and have further
developed their skills, knowledge and behaviour to:
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manage and develop self and personal qualities
work with others, develop and maintain relationships
build teams and enable successful outcomes
develop networks outside/complementary to medicine
manage and use resources effectively
facilitate change
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plan appropriately and achieve results to improve health care services and
patient safety
set direction and communicate the vision.
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Management
Fellows will be expected to demonstrate that they have negotiated learning
experiences to improve their effectiveness in management and have further
developed their skills, knowledge and behaviour to:
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develop and expand awareness of self and others in the context of a
constantly changing NHS and health care system
understand the pressures on and changes occurring in the NHS and health
care system
understand the allocation of resources and financial governance in the NHS
understand the interdependency of personal, organisational and NHS goals
develop the ability to contribute effectively to strategic planning and deliver
effective operational management to achieve strategic goals
Post CCT Fellowship in Palliative Renal Medicine
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develop effective operational management skills according to organisational
guidance/policy (eg appraisal, interview and selection, disciplinary
processes, complaints, clinical governance for the organisation)
develop personal skills:
o Team working
o Motivating
o Influencing
o Negotiating
o Delegating
o Managing time (self and others)
acquire skills needed to enable successful recruitment, interview and
selection of staff
Education
Fellows will be expected to demonstrate that they have negotiated learning
experiences to improve their effectiveness in an education role and have
further developed their skills, knowledge and behaviour to:
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broaden experience of teaching and understanding of work-based learning
o Locally
o Regionally
o University (undergraduate and postgraduate medicine)
develop links with other organisations, including:
o Deaneries
o GMC
o University (undergraduate and postgraduate medicine)
develop self-awareness to understand your own learning needs and
implement strategies and mechanisms to address these, including active
participation in:
o CPD
o Appraisal
o Revalidation
acquire skills needed to increase awareness of the role that management of
learning can have within the health care setting and develop the ability to
apply the learning theory to the clinical context, including successfully
completing:
o Supervisor’s course
o Educational supervision course
Research
Fellows will be expected to demonstrate that they have negotiated learning
experiences to improve their effectiveness in a research role and have further
developed their knowledge, skills and behaviour to:
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actively participate in online and local opportunities to meet and learn from
established researchers
develop skills in research methodology
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develop critical appraisal skills
Post CCT Fellowship in Palliative Renal Medicine
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Post CCT Fellowship from Renal Medicine
Knowledge
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Symptom prevalence in patients with stage 4-5 CKD
Detailed pharmacological knowledge of symptom management in renal
disease
Non-pharmacological methods of symptom management
Knowledge of the MDT from a palliative care perspective and the
benefit it can bring to the patient’s care.
Knowledge of community services and how they can be mobilised to
support patients towards the end of life
Knowledge of systems used in primary care to manage such patients,
such as end of life care registers, the Gold Standards Framework and
how to access them
Knowledge of the limitations of community-based services
Understanding of important ethical concepts such as withdrawing and
withholding treatment, advance care planning
Know about the role of the hospice for inpatient and outpatient care
Know about the role of the hospital/hospice chaplaincy service and
how to refer patients
Know about risk factors in bereavement, services available and how to
refer.
Skills/behaviours
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Ability to tailor a consult towards symptom assessment, management
and control
To develop advanced communication skills
Ability and willingness to engage patients in shared decision making
about treatment choices
Ability to conduct a detailed holistic assessment including physical,
psychological, social and spiritual domains
Willingness to refer to other members of the multi-professional team
Ability to weigh up ethically complex situations and provide
advice/direction to colleagues when faced with difficult clinical
decisions
Experience
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Opportunities for networking with palliative care colleagues and
developing contacts.
Working with hospice inpatient and community services
Experience of a specialist palliative care (hospice) MDT meeting
Working with hospital specialist palliative care team
Visits to primary care, Gold Standards Framework meetings and home
visits
Visits with District Nurses
Post CCT Fellowship in Palliative Renal Medicine
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Post CCT Fellowship from Palliative Medicine
Knowledge
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Knowledge of the various degrees of renal impairment and their
significance
Knowledge of different forms of dialysis, their benefits and burdens
Knowledge of the use of dialysis in symptom management and its
place in palliation
Knowledge of the process of dialysis and transplantation
Detailed knowledge of pharmacology, especially drug handling in renal
failure, cardiovascular disease and consequent polypharmacy
Detailed knowledge of the drug treatments available to a patient at
various stages of chronic kidney disease and of how to modify
prescribing accordingly
Knowledge of the role of the pre-dialysis team and the conservative
kidney management clinic and their interface with primary and
specialist palliative care.
Knowledge of the prevalence of symptoms in patients with stage 4
CKD and their management
Knowledge about the use of specific palliative treatments, such as iron
and erythropoietin for symptomatic management of anaemia.
Knowledge of the diagnosis and management of common co-existing
conditions such as diabetes, COPD
Skills/behaviours
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Ability and willingness to discuss treatment and care options with
patients considering withdrawing from dialysis, embracing shared
decision making with patients
Appreciation of the complexities of patient withdrawal from treatment,
including physical, psychological, social and spiritual aspects
Prescribing in different stages of renal failure
Palliative management of patients with multiple co-morbidities and the
resultant polypharmacy
Experience
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Opportunities for networking with nephrology colleagues and
developing contacts
Undertaking joint clinics and ward rounds with nephrology colleagues
Exposure to dialysis units and their MDTs
Talking with patients on haemo and peritoneal dialysis about the
practicalities of treatment
Experience in transplantation, especially in decision-making when a
transplant fails
Experience of decision-making for patient referrals with acute kidney
injury
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Outcomes and Assessment
By the end of the Fellowship, the physician will be able to deliver high quality
palliative renal care to patients who choose conservative management, to
symptomatic patients on or awaiting dialysis, and manage patients and their
families who withdraw from dialysis. They will act as an interface between the
two specialities to improve communication and appropriate management of
the ever increasing elderly population with multiple co-morbidities They will be
equipped to advise on symptomatic management of patients and support
them in the community without admission to hospital where possible and to
help facilitate timely discharges for those whose preferred place of care is at
home.
The success criteria for the Fellowship will be agreed by the Fellow,
educational guides and employing Trust at the outset and will include as a
minimum:
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360degree feedback of the Fellow
reflective practice using the resource on
http://www.jrcptb.org.uk/trainingandcert/ST3SpR/Documents/Guidance%20notes%20for%20Trainee%20and%20Tr
ainer%20in%20Palliative%20Medicine%20for%20the%20Record%20o
f%20Reflective%20Practice%202012.pdf
 a written report to both SACs from the Fellow and educational guides
including aspects of the post that you may do differently in future
 a presentation to the Trust renal and palliative care departments
 clinical audit
Authors and affiliations
Dr Fiona Hicks, Consultant in Palliative Medicine Leeds Teaching Hospitals Trust, chair
SAC in Palliative Medicine
Dr Lynne Russon, Consultant in Palliative Medicine, Sue Ryder Wheatfields
Dr Shareen Siddiqi, Consultant Nephrologist Sheffield Teaching Hospitals Foundation
Trust
Dr Patricia Brayden, Consultant in Palliative Medicine and Director of Medical Services St
Catherine's Hospice, West Sussex
Prof Edwina Brown, Consultant Nephrologist Imperial College
Dr Lucy Smyth, Consultant Nephrologist, Royal Devon and Exeter NHS Foundation Trust
References
1. Caskey F, Dawnay A, Farrington K, Feest T, Fogarty D, Inward C, Tomson CRV:
UK Renal Registry Report 2010. Bristol, UK: UK Renal Registry, 2011
2. Office of National Statistics (ONS) Cancer Incidence and Mortality in the UK,
2008-10. www.ons.gov.uk/ons/dcp171778_289890.pdf Accessed 31/05/2013
3. Saini, T., F. E. Murtagh, et al. (2006).Comparative pilot study of symptoms and
quality of life in cancer patients and patients with end stage renal disease. Palliat
Med 20(6): 631-636
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4. Gomm, S. and K. Farringdon (2009). End of Life Care in Advanced Kidney
Disease: A Framework for Implementation. N. E. o. L. P. N. K. Care. Suffolk, National
End of Life Care Programme.
5. GMC (2010). Treatment and care towards the end of life: good practice in decision
making. London, UK.
6. Dixon, J. J., J. E. Marsh, et al. (2010). "Palliative care: A year on the Liverpool
Care Pathway in renal medicine." British Journal of Renal Medicine 15(1): 4-7.
7. The Marie Curie Palliative Care Institute (2008). Guidelines for LCP Prescribing in
Advanced Chronic Kidney Disease. Liverpool.
8. Hussain J, Mooney A and Russon L. Comparison of survival analysis and palliative
care involvement in patients aged over 70 years choosing conservative management
or renal replacement therapy in advanced chronic kidney disease. Palliat Med June
2013 Don't have full reference yet.
9. Chadna SM, Da Silve-Gane M, Marshall C et al. Survival of elderly patients with
stage 5 CKD: comparison of conservative management and renal replacement
therapy. Nephrol Dial Transplant 2011; 26(5): 1608-1614
Post CCT Fellowship in Palliative Renal Medicine