Caring for someone with renal failure at the end of life

Please be aware - this information is for healthcare professionals

Renal failure occurs when the kidneys can no longer filter excess water and waste products from the blood , which are normally passed out of the body as urine. There are many causes of renal failure. It is a complication of long-term conditions such as diabetes and high blood pressure, but it also can develop quickly due to severe infections.

What are the symptoms?

Symptoms of renal failure include:

  • fatigue and drowsiness
  • confusion
  • water retention (eg swelling of the feet and legs)
  • shortness of breath
  • nausea and loss of appetite
  • passing small amounts of urine or none at all
  • anaemia, which can cause dizziness and worsen the above symptoms.

How can renal failure affect people at the palliative and end of life stage?

Renal failure that is not reversible, and where dialysis is not possible or is not chosen by the patient, will lead to progressive confusion, loss of mobility and sometimes rapid deterioration in the person’s level of consciousness.

If renal failure complicates another advanced illness, common symptoms in both conditions such as fatigue, itching, drowsiness, nausea and loss of appetite will get worse.

Renal failure may increase sensitivity to some medications, leading to more side effects and discomfort. With specialist advice, medication can be adjusted so that symptoms such as pain from other conditions continue to be managed and controlled. This is particularly important, as certain drugs may carry restrictions for kidney patients being treated with dialysis or transplantation, but patients should be able to benefit from these medications at end of life. 

Be aware that pain is not always a symptom of renal failure, although stiffness of joints and excess fluid in the limbs can and does cause pain to patients.

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What special considerations should I make in my approach to providing care for someone with renal failure?

When renal failure is the main cause of illness, it can lead to a rapid decline. Prompt planning regarding the patient’s wishes and potential care at home is vital.

If the patient experiences renal failure alongside another advanced condition, such as cancer, this will worsen the patient’s prognosis and lead to a faster deterioration.  Dialysis is unlikely to be considered at the end of life stage. Instead, supportive measures, such as making sure the patient is as comfortable as possible and that symptoms are well managed, are the most important.

It’s essential to adjust medication to avoid side effects such as clinical excitation, agitation, confusion, toxicity and seizures caused by the build up of toxins which the failing kidneys are unable to filter away.

Caring for patients with renal failure who are not having dialysis is much the same as caring for people with other advanced conditions with increasing dependency. Sometimes patients may be on fluid restriction to lessen the effects of water retention but this is often relaxed during the last days of life. Explaining this to patients and their families and reassuring them is helpful at this stage. 

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Points to remember 

  • Renal failure is a common complication of long-term conditions or of acute illnesses such as sepsis.
  • Where there is no reversible cause and dialysis is not possible, prognosis is likely to be short.
  • Prompt assessment of the patient’s symptoms and adjustment of medication is helpful.
  • Planning for future care, such as transfer to a hospice or care at home, will need to be rapid.

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