The PalliEM Podcast:
Episode 9 –  – with Dr. Mariana Murea, MD

Episode 9 Production:

Podcast Guest:
Dr. Mariana Murea, MD
Link to Dr. Murea’s Bio

Podcast Host:
Dr. Justin Brooten, MD

Podcast Editing & Production:
Michelle C. Brooten-Brooks

Transcript:

 00:00:00:00 – 00:00:09:16

Justin Brooten, MD:
This is the PalliEM Podcast, a production of PalliEM.org at the intersection of palliative and emergency medicine. I’m your host, Justin Brooten.

 

00:00:09:16 – 00:00:21:01

Justin Brooten, MD:
Today, I’m joined by Dr. Mariana Murea. Dr. Murea is an associate professor and a practicing nephrologist and clinical investigator at the Wake Forest School of Medicine in Winston-Salem, North Carolina.

 

00:00:21:03 – 00:00:43:17

Justin Brooten, MD:
She is a recipient of NIH funded Awards and the Mid-career Clinical Investigator Award at the Wake Forest School of Medicine. Her research has focused on addressing gaps in the care of patients with ESKD (End-stage kidney disease) on hemodialysis, with an emphasis on patient-centric care. She is dual board certified in both internal medicine and nephrology. Dr. Murea, thank you so much for joining me today.

 

00:00:43:17 – 00:00:54:17

Mariana Murea, MD:
Thank you very much for the invitation. And it’s an honor for me to, to talk about patient-centered care in those individuals who need hemodialysis.

 

00:00:54:17 – 00:01:05:12

Justin Brooten, MD:
So one of the things that I’ve appreciated in talking with you previously is how you’ve been able to take a field that a lot of people don’t, don’t think of as trying to marry patient-centered care with the kind of things we do to extend life, and you found a way to do that. So as a nephrologist, to what extent have you found palliative care to be important in the management of end-stage kidney disease?

 

00:01:16:22 – 00:01:44:18

Mariana Murea, MD:
Yeah, that’s a great question. End-stage kidney disease is unfortunately life-limiting incurable illness is of now. Nevertheless, it is an illness that can be treated with some of the most revolutionary means ever developed in medical science, which are dialysis and kidney transplantation.

00:01:44:20 – 00:02:12:19

Mariana Murea, MD:
But this means that patients with end-stage kidney disease on dialysis live with a burdensome condition, and they often have many other comorbid illnesses. So having end-stage kidney disease means that patients inherently suffer from a plethora of symptoms that generally tend to grow in intensity with time, unless the patient is eligible and can receive..and receive a kidney transplant.

 

00:02:12:19 – 00:02:44:15

Mariana Murea, MD:
So these perennial symptoms include fatigue, insomnia, pain, itching, poor appetite and so on. And palliative care, as we know, focuses on symptom management and goals of care assessment with a focus on quality of life. When traditional treatments do not offer sufficient treatment relief, symptom relief, I’m sorry, and I’m not expected to add appreciable quantity of life without further deteriorating the quality of life.

 

00:02:44:15 – 00:03:30:00

Mariana Murea, MD:
Right? So, some things in the trajectory of end-stage kidney disease, a moment comes when treatment with full intensity dialysis, let’s say three times a week, hemodialysis three and a half to 4 hours. But each session is no longer in the best interest for the individual who enters that end-of-life stage. And that is the point where one could consider decreasing the intensity of hemodialysis by either having less frequent hemodialysis treatments before dialysis treatments in this form of decremental hemodialysis for the purpose of palliative care and transition into end-of-life moments is focused on quality of life, then biochemical targets then.

 

00:03:30:00 – 00:03:52:05

Mariana Murea, MD:
So, to answer your question, palliative care is also a requisite component of a holistic system of care for end-stage kidney disease that, that can offer adaptive dialysis treatments according to different stages and different needs of each individual on dialysis.

 

00:03:52:05 – 00:04:11:21

Justin Brooten, MD:
That’s excellent. I really I like how you you talked about adjusting, adjusting treatment to fit the needs of the patient. And thinking about that, the weighing the bio, the biomedical markers we use with, with the needs of the patient and trying to think about their quality of life and trying to balance both of those things. It’s a dynamic process. So, how do you find that the needs for palliative care are addressed in patients with end-stage renal disease?

 

00:04:18:21 – 00:04:36:09

Mariana Murea, MD:
Well, so in an ideal world, each dialysis unit would have a palliative medicine specialist, right, that works in concert with the nephrologist and the dialysis personnel and by that and I’d I’m referring to dialysis nurses, dietitians and social workers. And as a group, this interdisciplinary dialysis team and palliative care team would address and adapt dialysis and medical treatment plans corresponding to the stage of illness for each individual with end-stage kidney disease. But in real world, it comes down to the nephrologists themselves to employ medications for treatment of insomnia, itching, pain and tend to the patients’ psychological needs and initiate and apply discussions and offer palliative dialysis in proper scenarios.

 

00:05:13:21 – 00:05:28:10

Mariana Murea, MD:
But with the current model of care that is rather metric-driven, high-paced volume of care, rewarding, there is a gap still in the way kidney palliative care is practiced in the community.

 

00:05:28:10 – 00:05:36:06

Justin Brooten, MD:
Yeah, it sounds like you’ve, you’ve had to, you’ve had to employ those techniques that you’ve picked up just to make sure that those needs get met.

 

00:05:36:06 – 00:06:18:05

Mariana Murea, MD:
Yes, And, you know, I think I think they should be employed a lot more often than I, I admit I am doing. And, you know, our patients, we have to remember, though, that and even when I need help and referring the patient to palliative care clinics, it’s very difficult for them to actually go to those appointments because they, they deal with so many other, you know, kind of schedules and appointments and dialysis itself that often we, we are left, you know, sort of seen by ourselves as practicing nephrologists to try to meet all of this dynamic and complex needs.

 

00:06:27:21 – 00:06:43:18
Justin Brooten, MD:
You know, that’s an excellent point. They already have so much contact with the medical field already because of dialysis itself and because of their other medical visits. So, you’re right. Trying to have, trying to get them to fit another appointment in their schedule is pretty difficult.

 

00:06:43:18 – 00:06:57:12

Mariana Murea, MD:
Yeah. And there are only five days in a week right, then for many of them, three days are already occupied with dialysis. And the other two are, you know, kind of at least to live at least some of that life.

 

00:06:57:12 – 00:07:10:05

Justin Brooten, MD:
I’d imagine this is the case with other services that they need, but because of how much time they spend on dialysis, whenever those things can be bundled in to the care they’re already getting or concurrent with that process, it makes a lot of sense.

 

00:07:10:05 – 00:07:24:07

Justin Brooten, MD:
So dialysis is not typically associated with palliative care, but you have patients on dialysis that are closer to the end-of-life and you figured out how to incorporate a palliative care approach at the same time as managing your dialysis. Can you tell us more about that?

 

00:07:25:15 – 00:08:22:09

Mariana Murea, MD:
Yeah. So, you know, there are certain clinical contexts when, in which I offer palliative dialysis or even dialysis withdrawal, and for example, patients with an estimated life expectancy of less than six months or who are irreversibly bedridden and have frequent hospitalizations and are on perhaps mechanical support or who have severe cognitive deficits and are very, very frail. So, in these situations, I meet with patients, families, and caregivers, and I initiate end-of-life discussions, and then I discuss the pros and cons of palliative dialysis, because with palliative analysis, the treatment goal, again, it’s aimed at quality of life rather than medical parameters.

 

 

 

00:08:22:09 – 00:08:58:06

Mariana Murea, MD:
And so that in, in the case of intensive hemodialysis and is caused adjusting or dialing down the treatment to either twice a week or still three times a week, but shorter sessions like two and a half hours or three and a half hours per dialysis treatment. But I want to emphasize that there is no single formula for palliative decremental dialysis, end-of-life discussions are a long process, and the decisions are very complex.

 

00:08:58:06 – 00:09:28:21

Mariana Murea, MD:
And at the end of that process, the direction may be towards the decremental palliative dialysis and then dialysis withdrawal or proceed directly to dialysis withdrawal or even maintain for the intensity dialysis. And sometimes the first decision is, or the first conclusion that is drawn after an end-of-life discussion and meeting is not the last decision. So revisiting goals of care should always be kept in mind when deemed appropriate.

 

00:09:28:21 – 00:09:46:02

Justin Brooten, MD:
That’s so true. It’s not a, you mentioned that before, you said ongoing goals of care. And that’s one of the things about palliative care. It’s not a static process. Their co-morbidities change, their treatment burden changes. The other things they are dealing with changes. So, so the target moves and that’s very true.

 

00:09:46:02 – 00:09:47:21

Mariana Murea, MD:
Right. Yeah. And you know, patients and caregivers go through different coping mechanisms and for some people, you know, obviously requires more time to kind of digest or adjust to the idea that, you know, things are moving to a point where, you know, medicine has reached its limits.

00:10:11:09 – 00:10:23:02

Justin Brooten, MD:
And I think I think dialysis probably because it’s just become such a routine part of somebody’s life in many cases, that’s such a big decision to, to transition off of.

 

00:10:23:02 – 00:10:43:00

Mariana Murea, MD:
Right, right, right. And that’s because, you know, when we start dialysis, rightfully so, we say that now you reach a point and you, meaning the individual afflicted with end-stage kidney disease, reach a point where without dialysis, death is imminent.

 

00:10:43:00 – 00:11:31:17

Mariana Murea, MD:
And so for them now to come and say, you know, we reached a point where even with dialysis, we are getting there, and it’s just becoming more and more maybe burdensome for, for everybody just to see how difficult it is to tolerate dialysis. So, yes, I think for, for some people, it’s they, they have obviously a lot of emotional turbulence when they hear that. Other people just welcome that discussion with a big sense of relief. And other people, you know, is anywhere in between, and they require, or they want to have thoughts about that.

 

00:11:31:17 – 00:11:41:07

Justin Brooten, MD:
You’ve mentioned a bunch of the different techniques you’ve had to use to try to address the palliative care needs in your patients, especially since they already have so much contact with the medical system.

 

00:11:41:07 – 00:11:50:18

Justin Brooten, MD:
You really need to provide a lot of that care yourself. What are some of the things that nephrologists learn in training about palliative care, or is there much that they learn about palliative care?

 

00:11:50:18 – 00:12:28:07

Mariana Murea, MD:
Yeah, that’s, that’s an excellent point. So, for example, when, when I trained my fellowship did not have the nephrology palliative care curriculum, but that, that’s because the attention to palliative care in nephrology in patients with kidney disease and patients on dialysis has grown exponentially just in the past few years. So, these days, more and more institutions, academic institutions, have a nephrology   palliative care curriculum integrated within that.

 

 

00:12:28:09 – 00:13:12:08

Mariana Murea, MD:
The whole, you know,  kind of nephrology education that we provide to our fellows. And also, on the website of the American Society of Nephrology. And many of these the National and International Nephrology meetings, there are a, that is more and more talk of, you know, kind of organized, structured, didactic sessions on palliative care. So, you know, I entered the practice of palliative dialysis and you know, palliative care in patients with kidney disease without necessarily a formal education.

 

00:13:12:08 – 00:13:51:08

Mariana Murea, MD:
But, you know, just by listening to the patients, feeling for their needs, and obviously reading and talking with other people, going to conferences and listening through webinars, it’s a skill that grows on you and it’s very compassionate and it’s something that our patients definitely need and think there will be more and more, you know, even dialysis systems or networks that will start probably offering palliative care on a more routine basis.

 

00:13:51:08 – 00:14:01:22

Mariana Murea, MD:
And that’s such a such a setup is already in some parts of the country, but it’s still kind of a big gap about that.

 

00:14:01:22 – 00:14:13:00

Justin Brooten, MD:
Well, it’s, it’s good to hear that, that’s a an option that’s starting to become available, even if it’s really limited at this point. It sounds like there’s people like you that are advocating for that, which is a good thing.

 

00:14:13:00 – 00:14:28:08

Justin Brooten, MD:
So one of the things that’s really fascinating to me is thinking about dialysis as a means of comfort measure and how does it function like that for some of your patients that are on palliative dialysis? And how how does that work exactly?

 

00:14:28:08 – 00:15:06:14

Mariana Murea, MD:
Yeah. So, in my experience palliative decremental dialysis always fulfilled its anticipated role of comfort and end-of-life transition when I think that that approach would be useful. And very often I observed that patients and caregivers had this sense of lifting a burden off the shoulder, and it was a sense of, ‘Wow, I don’t have to come to dialysis three times a week when I feel so sick all the time?’

 

00:15:06:15 – 00:15:37:02

Mariana Murea, MD:
Or you know, I know the end is coming and that’s okay If I don’t come because the doctor said so. So, it’s, it’s a big, big sense of relief lifting off a big burden from their mindset. And then not only that, it basically gives them more time to, to cope with the end-of-life symptoms or, or time to, to spend with their loved ones.

 

00:15:37:04 – 00:16:13:20

Mariana Murea, MD:
But it also is it’s kind of used, I see it as a very compassionate way of transitioning to dialysis, withdrawal and hospice. So, for some patients, you know, it’s, it’s difficult to let it go all or nothing just from one day to another. So, it’s they have more of that kind of option of let’s, let’s try to, you know, do a little bit less intense sessions.

 

00:16:13:22 – 00:16:50:06

Mariana Murea, MD:
But now I also want to mention so these are the advantages of the palliative decremental dialysis there. But there could be some drawbacks when you know, when we think about palliative decremental dialysis and this have to be outlined and considered during a palliative treatment plan for these patients. And what I’m referring to is the possibility of developing volume overload in patients that are dialyzed this frequently so by all means, we don’t want to induce a prolonged suffering or more suffering for these patients.

 

00:16:50:06 – 00:17:24:15

Mariana Murea, MD:
So I’m offering generally palliative dialysis to, to those who have very small gains to gains, beating dialysis treatment. And that’s often the case in patients what near end of life, because they don’t have a lot of nutritional intake, unfortunately. And I also discuss with my patients and their caregivers the goal of staying out of the hospital since the aims of palliative dialysis is for the patient to spend more time with their loved ones and have less intrusive procedures.

 

00:17:24:15 – 00:17:53:16

Mariana Murea, MD:
Right. So I often have these no further hospitalizations agreement declared between the patient care givers, myself as a provider, as the other staff we need, and even the nursing home personnel as applicable. And that you know that it’s I find it is very considerate of, you know, the, the patients, the family and all of the resources that are available.

 

00:17:53:16 – 00:18:14:17

Justin Brooten, MD:
That’s really you know, this is so interesting. I love hearing about this because it’s what you said. You said several things there that I think are excellent. One, the idea that just abruptly stopping is a really, really tall cognitive barrier to overcome for a lot of people. So, I think the idea of kind of graduated decremental, you said, you know, decremental dialysis.

 

00:18:14:18 – 00:18:38:02

Justin Brooten, MD:
I think that’s, that’s brilliant because it does it gives them that chance to kind of enjoy the benefits of the extra time. And like you said, the ones who are closer to end-of-life anyways, they’re probably not, you know, having lots of fluid gain. So it makes a little more sense anyways. It’s more feasible and I think you’re right, it gives them some time to process, it gives them some time to think about the care transition, which I think is a big deal.

 

00:18:38:04 – 00:18:59:05

Justin Brooten, MD:
And it actually reminds me in some ways of when we have people in the hospital, they’ve had multiple hospitalizations. It could be something totally different. It could be, you know, somebody with dementia that keeps getting recurrent infections. And sometimes the family wants that last try of doing antibiotics or something. And they may know they may come to the conclusion, okay, the next time we won’t do them anymore.

 

00:18:59:07 – 00:19:17:20

Justin Brooten, MD:
But that last hospitalization or two, they have a chance to sort of do some limited treatments and kind of see how they do. And it doesn’t feel like this abrupt transition. They kind of get a chance to sort of slowly, slowly transition the care goals as opposed to some abrupt change. And I think just in human nature, it just makes more sense.

 

00:19:17:20 – 00:19:38:23

Justin Brooten, MD:
People are going to have a easier time with that. So I think that’s, that’s really brilliant. And the other thing that highlights what you said is, it’s really tailored to the patient and the family. You know, the not, you know, not going back to you. You know, let’s make sure you don’t want to go back to the hospital because the goal here is not to completely medically optimize you, but it’s to improve your quality of life.

 

00:19:39:01 – 00:19:57:22

Justin Brooten, MD:
So, those negotiation plans, they take more time to do that. It takes a lot more time, but it’s patient and family-centered. You know, tell me tell me about that. I think that that’s really, it’s beautiful. The word kept coming to my, to my mind, as you were talking about this, you said compassion. I think it is, It’s kind of beautiful.

 

00:19:57:23 – 00:20:06:22

Justin Brooten, MD:
You know, when you make a plan that says, I’m going to think about you as an individual and how to help get you through this the best we can. Tell me more about that.

 

00:20:06:22 – 00:20:42:07

Mariana Murea, MD:
Yes, I mean it’s to offer patient-centered care obviously it requires a lot more time at any level and in any medical field. And particularly also, actually, even more so I should say, when it comes to end-of-life discussions and, you know, having to weigh all of these different aspects of what is end-of-life going to look like, It’s and doing this for mortality analysis, which is part of is we said a, a form of the mechanism of coping with end-of-life.

 

00:20:42:07 – 00:21:27:23

Mariana Murea, MD:
But it’s you know, at the same time, you know, you’re, you’re going to get sicker. So, I it’s, it’s you know I’m, I’m preemptively trying to show them that this is how it’s going to look. I mean, we were trying to keep the symptoms at bay as much as possible, but it’s things will still, regardless get worse. And I, I find that social workers at the dialysis unit are extremely helpful, nurses are very, very critical also to be part of that meeting, not only the social worker but also the nurses, because they see a lot more often than we as doctors see them on dialysis and how much they suffer.

 

00:21:28:01 – 00:21:58:18

Mariana Murea, MD:
And, you know, just having hearing, you know, kind of you know the impressions and the heartfelt advice from all the members of the dialysis team, It’s a very good tool. And maybe I should say tool. It’s something that actually family members or caregivers of patients do appreciate it. And we want to see, you know, it’s kind of we all care about them.

 

00:21:58:18 – 00:22:19:13

Mariana Murea, MD:
And, you know, it’s not that we either we don’t want to offer dialysis anymore, but at the same time, you know, they do get sicker and they go to the hospital and come out and they are in the same condition at best, but usually worse. And, you know, just the cycle of worse and worse and worse and.

 

00:22:19:15 – 00:22:39:04

Mariana Murea, MD:
Yeah, so it’s, it is been very rewarding to, to that you know you especially when you see how appreciative the family members and caregivers and the patients are to open that discussion and then it becomes, yeah.

 

00:22:39:04 – 00:22:51:16

Justin Brooten, MD:|
Yeah, that’s, that’s awesome. I imagine to especially just because you have long-term relationships with these patients and these families, it, it’s just such a kind of a kind of a meaningful experience.

 

00:22:51:16 – 00:22:55:21

Justin Brooten, MD:
Painful, I’m sure, but, but really meaningful to be able to help them with that transition.

 

00:22:55:21 – 00:22:58:21

Mariana Murea, MD:
Yeah.

 

 

 

00:22:58:22 – 00:23:16:07

Justin Brooten, MD:
One of the questions I have, too, is as wonderful as all of the work you’re doing in patient-centered care is, what are some of the obstacles that you face in trying to initiate and conduct palliative dialysis in patients with end-stage kidney disease?

 

00:23:16:07 – 00:23:40:11

Mariana Murea, MD:
Yeah. So, I mean indeed it’s as I said, that is a great critical gap, a large gap in the employment of palliative care in patients with advanced kidney disease and on dialysis and there are, there are many reasons for this, but I would probably try to mention just a few.

 

00:23:40:14 – 00:24:13:19

Mariana Murea, MD:
For example, first and foremost, I would say that the research and the knowledge on palliative dialysis has been very scarce in the incorporation of palliative care curriculum within nephrology. Specialty, specialty curriculum and policy training, although has been growing, is not uniformly present across academic centers. So many nephrologists were not yet finished with their training, don’t feel as comfortable in having these discussions.

 

00:24:13:19 – 00:24:47:00

Mariana Murea, MD:
Or recognizing when, you know, it’s probably time to start having some, some early discussions around that end-of-life plans. And then there is also the issue of dialysis unit operationalization, because in order to accommodate varied dialysis schedules is a challenge because it creates a string of administrative needs that must be fit all of them into an efficient workflows and properly staff units, right?

 

00:24:47:02 – 00:25:20:05

Mariana Murea, MD:
Not overstaffed or understaffed either. And then there is, of course, the aspect of metrics-driven dialysis care, and treatment-based reimbursement and palliative dialysis, and less frequent dialysis treatments would inevitably interfere with this aspect by causing larger deviations from metric targets such as phosphorus levels or calcium level or what impact BPH level of or, you know, frankly in that, in that subgroup of population, it becomes meaningless.

 

00:25:20:05 – 00:25:45:00

Mariana Murea, MD:
But yet, you know, it’s it goes on the metrics and you know as well as fewer dialysis treatments. So, with all this being said, though, that is more and more optimistic than ever. As I said, that, you know, patient-centered care advanced-stage kidney disease and patients who need dialysis is receiving more and more attention in the field of nephrology.

 

00:25:45:00 – 00:25:50:19

Justin Brooten, MD:
Yeah, you know, it’s good to hear. It seems like there’s, there’s a lot of obstacles to still be navigated.

 

00:25:50:21 – 00:26:10:18

Justin Brooten, MD:
And I wonder to even just, you know, think things like insurance policy and, you know, the way metrics are analyzed, You know, if you have a subcategory that kind of keeps those patients from, from getting the nephrologist penalized for trying to do the right thing, you know, if they’re, if they’re not on the same dialysis plan, that would be helpful. But that doesn’t exist yet.

00:26:10:18 – 00:26:52:12

Mariana Murea, MD:
Yes, Yes, exactly. So I think obviously, you know, kind of being the metric-driven system, then, you know, kind of policies that underlie all of this practice to such an extent, you know, will need to be reformed, Right? All the policies. And, you know, the way care is evaluated, the way patient care is evaluated way beyond the metrics. And but it would be it will be very complex to as we know to, to evaluate quality of care is very difficult.

 

00:26:52:14 – 00:27:19:11

Mariana Murea, MD:
And I’m not just talking only about dialysis. I’m talking about, you know, just across all specialties and all these elements that I also mentioned, you know, more research and better education, you know, are all intertwined. You know, there is, you can have you know, even if you had, you know, policies or I should say policies don’t change unless you have good evidence.

 

00:27:19:11 – 00:27:34:11

Mariana Murea, MD:
And once you have good evidence, then, you know, you need sufficient training and implementation. And so, you know, such a change is not going to obviously happen overnight. But we will get there, I’m sure.

 

00:27:34:11 – 00:27:55:05

Justin Brooten, MD:
Well, I just I’ve really enjoyed listening to your responses and, and what you’re doing to try to, to try to address the needs for this, for this patient population that I think has, could get overlooked easily. And the needs that they have that need to be addressed and kind of novel and creative ways. So, I really appreciate that. And thank you so much for for joining me today.

 

00:27:55:05 – 00:27:59:23

Mariana Murea, MD:
Thank you so much for the invitation. Thank you for having me. Thank you.

 

00:27:59:23 – 00:28:07:09

Justin Brooten, MD:
For more information on current topics in the fields of palliative and emergency medicine, please visit PalliEM.org.