Associations of Specialist Palliative Care and Advance Care Planning with End-of-Life Outcomes in Kidney Transplant Recipients: A Single-Center Retrospective Study in Spain

Background: Evidence on specialist palliative care and advance care planning (ACP) for kidney transplant recipients (KTRs) near the end-of-life remains limited. Methods: We conducted a single-center retrospective observational study (electronic health record chart review) at a tertiary transplant center in Madrid, Spain. We included adult KTRs who died between January 1, 2021, and December 31, 2023, with sufficient end-of-life documentation; SARS-CoV-2-related deaths and deaths outside health care settings or with insufficient records were excluded. We compared end-of-life outcomes by specialist palliative care (PC) involvement and by ACP category. Outcomes included documented symptoms within 5 days before death, documented moderate-to-severe suffering within 48 hours (based on narrative chart descriptors), documented intent to prioritize symptom control in the last 24 hours, aggressive treatments within 7 days (intensive care unit/intermediate respiratory care unit admission, surgery/percutaneous intervention, renal replacement therapy, and/or intensive in-hospital management), place of death, and documented family positive perception of end-of-life care. Results: Fifty-nine deceased KTRs were analyzed; 20 (33.9%) received PC, and 39 (66.1%) did not. Compared with no PC, PC involvement was associated with a lower prevalence of documented symptoms within 5 days before death (5/20 [25.0%] vs. 38/39 [97.4%]; p < 0.001), documented moderate-to-severe suffering within 48 hours (0/20 [0%] vs. 36/39 [92.3%]; p < 0.001), and a higher documented intent to prioritize symptom control in the last 24 hours (20/20 [100%] vs. 22/39 [56.4%]; p < 0.001). PC involvement was also associated with fewer deaths in high-acuity settings and more home or hospice deaths ( p < 0.001). Across ACP categories, comprehensive ACP was associated with fewer documented symptoms within 5 days (1/9 [11.1%] vs. 18/18 [100%] with no ACP; p < 0.001) and no documented moderate-to-severe suffering within 48 hours (0/9 [0%] vs. 18/18 [100%] with no ACP; p < 0.001). Conclusions: In this single-center retrospective study, PC involvement and more comprehensive ACP were associated with more favorable end-of-life outcomes among KTRs. Prospective studies are needed to confirm these associations.