Terminal Uraemia Palliative Subcutaneous Symptom Control — ESENeph MCQ

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ModerateChronic Kidney DiseaseTerminal Uraemia Palliative Subcutaneous Symptom ControlESENeph

A 65-year-old man with CKD G4 (eGFR 16 mL/min/1.73m2) has been declining for 2 years. He has chosen conservative management. He now has intractable nausea, drowsiness, and myoclonus. His family are distressed. What symptom management approach is MOST appropriate in the terminal phase?

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Correct answer: C — Refer to palliative care for uraemic symptom management including subcutaneous medications

In patients on conservative (non-dialytic) kidney management who are entering the terminal phase, palliative care involvement is essential. Uraemic symptoms (nausea, drowsiness, myoclonus, pruritus) can be effectively managed with subcutaneous medications via a syringe driver: anti-emetics (cyclizine, haloperidol, levomepromazine), anxiolytics (midazolam for myoclonus and agitation), and analgesics (alfentanil — preferred over morphine as morphine metabolites accumulate in CKD). Oral medications are often impractical due to nausea. The focus shifts from disease modification to comfort and dignity. Family support, anticipatory prescribing, and preferred place of care arrangements are core components. Restarting dialysis at this stage would not be consistent with the patient's expressed wishes.

Reference: UKKA 2021 – Conservative Kidney Management; NICE 2021 – NG203; Thomas et al 2019 – Palliative Care in ESKD