Patient-Centered Care; Quality of Life; Renal Dialysis/economics Chronic kidney failure (CKD) is considered by the World Health Organization a pandemic disease with more than 850 million people affected worldwide with higher costs and requiring more resources than the majority of other health problems.¹ Many patients reaching end-stage CKD are frail, old, and complex. This Geriatric Nephrology elicits challenging decisions, one of which is renal replacement treatment (RRT). RRT carries a significant burden for the patient and can have disappointing outcomes such as high mortality, functional and mental decline, poor quality of life (QoL), more hospitalizations and aggressive procedures at end of life.²

Recognizing individuals who may not benefit from RRT can avoid unnecessary suffering to patients and families, as well as reduce social and environmental costs.

Obstacles to conservative and palliative care stem from misconceptions, fear of death, incapacity to communicate bad news, lack of staff and reimbursement and insufficient involvement of the nephrology community.³

Solutions include increasing training of nephrologists in palliative care, the use of prognostic tools and the development of communication skills to help in the process of shared decision-making, and advanced-care planning aligned with patients’ values.⁴ Preferences and the clinical state of seriously ill patients evolve over time, meaning we must be able to switch from a disease-centred to a more dynamic patient-centred treatment, where palliative care and tailormade palliative dialysis may be used to promote a dignified end of life.

The care delivery model should ideally have dedicated staff, established pathways, and partnerships with primary and palliative care departments, including cooperation with dialysis facilities.⁵

Reimbursing conservative care, similar to home-based RRT, could neutralize logistic biases associated with dialysis initiation. Nevertheless, it carries risks such as ageism, or pressuring or frail patients to forgo dialysis. Well documented decisions taken by a liable and multidisciplinar team, could help overcome these problems.⁶

It was shown that early introduction of palliative care ensures improved QoL and survival while reducing emergency visits, hospital admission, intensive procedures and hospital death.

Although strong evidence concerning the economic value of renal conservative treatment is missing, these patients seem to have lower nondialysis- related costs whilst maintaining many medical interventions, which emphasizes its role as an active treatment.⁷ Conservative care requires the use of medication, hospital admissions, hospice services, home visits, social, and nutritional support. Although many “out-of-pocket” expenses are missed (including related to the caregiver), its overall costs can still be less than that of RRT.⁸ Depending on the country’s health policy, it may be a good value-based approach.

Palliative care and conservative management improve outcomes and lower futile costs. To allocate patients to the right treatment option, taking into account the principles of autonomy, beneficence, no maleficence, and “distributive” justice, is a step towards the sustainability of Nephrology.