Transforming Internal Medicine: Palliative Care Insights

Palliative care has become an essential component of internal medicine, especially for patients with chronic diseases such as chronic kidney disease. This specialty is dedicated to improving the quality of life and relieving suffering for people facing serious, life-limiting illnesses. Palliative care is provided by interdisciplinary teams that might include physicians, nurses, social workers, chaplains, dietitians, and therapists. These teams address a wide spectrum of needs, not only medical but also psychological, social, and spiritual. The primary goal is to optimize quality of life for patients and their families by managing pain and other distressing symptoms, and by providing support through the course of a chronic illness.

Unlike hospice, palliative care isn’t reserved for the final stages of an illness. It can be integrated early and provided alongside curative or life-prolonging treatments. For chronic kidney disease, this means that patients may receive palliative interventions from the time of diagnosis, regardless of their age or disease stage. This approach benefits not only those with advanced disease but also those managing the symptoms and life changes associated with chronic kidney conditions over many years. There are an estimated 753 million people worldwide living with chronic kidney disease, with symptoms ranging from fatigue and pain to depression and cognitive impairment.

Patients with chronic kidney disease often experience a high symptom burden. Physical pain, persistent fatigue, nausea, shortness of breath, and pruritus are common complaints. Psychosocial distress is also prevalent, with anxiety and depression affecting quality of life. In advanced CKD, studies have shown a 35–40% higher likelihood of cognitive decline or dementia. Palliative care teams bring expertise in addressing such symptoms, using individualized assessment tools like the Edmonton Symptom Assessment Scale, which measures pain, activity, nausea, depression, anxiety, drowsiness, appetite, and well-being on a scale from 0 to 10. Management may involve both pharmacological and non-pharmacological strategies, ranging from specialized medications to counseling, dietary modifications, and spiritual support.

Nutritional and hydration status are critical issues in chronic kidney disease. Many patients are unable to maintain proper nutrition due to persistent nausea, loss of appetite, or dietary restrictions. Palliative care teams work with dietitians to develop personalized plans that maintain nutritional adequacy while accommodating disease progression and patient preferences. Protein intake, for example, is often adjusted to around 0.8 grams per kilogram of body weight per day for adults with advanced CKD, with even stricter regimens possible under close supervision.

One of the most significant distinctions in internal medicine is the difference between palliative care and hospice care. Although both focus on comfort and quality of life, palliative care can begin at any stage of a serious illness and is compatible with curative treatment. Hospice care, by contrast, is typically reserved for patients expected to live six months or less and who are no longer pursuing curative interventions. This distinction became more clearly defined in the 1980s, as the modern palliative care movement separated itself from the earlier hospice tradition. The result has been a broader and earlier application of palliative principles to chronic diseases, not just to those at the very end of life.

The integration of palliative care into internal medicine, especially for chronic kidney disease, accelerated throughout the 2000s. Research in this period demonstrated that early involvement of palliative care specialists improved symptom control, patient satisfaction, and family well-being, while simultaneously reducing unnecessary hospitalizations and overall healthcare costs. By 2011, over 90% of U.S. hospitals with more than 300 beds had established palliative care teams, though only 17% of rural hospitals with at least 50 beds had such programs. Globally, the uptake of palliative care varies; high-income countries like the United Kingdom and Canada have established policy frameworks supporting interdisciplinary palliative teams within their healthcare systems, while many low- and middle-income countries face persistent shortages of trained professionals and limited access to pain management resources.

Pediatric and geriatric populations with chronic kidney disease present unique challenges for palliative care. In children, symptom assessment is complicated by developmental and communication barriers, making it essential for providers to involve families and use age-appropriate tools. A 2022 study on children and young people with stage 5 chronic kidney disease highlighted the necessity of shared decision-making, communication, and symptom management tailored to the pediatric context. Pediatric nephrologists recognize the importance of palliative care, yet national surveys reveal that underutilization remains common due to limited training and misconceptions equating palliative care solely with end-of-life support.

Geriatric palliative care for CKD patients encounters additional hurdles, including frailty, multi-morbidity, and fragmented health and social services. Prognostication is often uncertain because older adults may experience gradual declines rather than sudden health events, making it difficult to time palliative interventions appropriately. Economic evaluations show that embedding palliative care into geriatrics can reduce hospitalization rates and emergency visits, improving both cost efficiency and patient outcomes. A meta-analysis estimated an average reduction in direct hospital costs of $3,237 per patient when hospital-based palliative care services were used, with even greater savings in cases involving multiple comorbidities.

Despite clear evidence of benefit, barriers persist. Disparities in access to palliative care are pronounced along racial, ethnic, and socioeconomic lines. African, Hispanic, and South Asian populations are at higher risk for chronic kidney disease but often have less access to palliative resources. In the United States, for example, 37% of end-stage kidney disease cases in African Americans are attributed to high blood pressure, compared to 19% among white individuals. Socioeconomic status compounds these disparities; even controlling for environmental factors, access to high-quality care remains uneven.

Certification and training standards for palliative care differ widely across regions. In the United Kingdom, palliative medicine specialist training is combined with internal medicine training over four years. In the United States, hospice and palliative medicine became a recognized physician sub-specialty in 2006, overseen by multiple specialty boards. However, the availability of formal training programs and interdisciplinary teams is patchy, particularly outside large urban centers.

Economic challenges are especially acute in geriatric palliative care. Older adults account for a disproportionate share of healthcare expenditures in their final years of life, often receiving aggressive treatments with limited benefit. Methodological difficulties in economic evaluation—such as defining appropriate outcome measures and control groups—have hampered coordinated research efforts. Even so, modeling studies suggest that scaling community-based palliative programs for older adults could reduce national health expenditures by up to 15% over a decade.

Ethical considerations remain central to palliative care, particularly regarding end-of-life decision-making. This involves complex choices about life-sustaining treatments, quality of life, and patient autonomy. In pediatric settings, decision-making often involves legal guardians, but palliative care teams strive to include the child’s preferences and voice whenever possible. Professional societies such as the European Association for Palliative Care and the American Geriatrics Society have called for systematic integration of palliative frameworks into all levels of internal medicine training and practice.

One striking statistic highlights the global challenge: of the forty million people expected to need palliative care each year, only about 14% actually receive it, and the vast majority of recipients live in high-income countries.