• In India, around 450 minor palliative care clinics most out of hospital, 90% of them are only in Kerala.
• No palliative care center have designated renal palliative care services.
• Palliative care competencies: maximize function/minimize symptoms/maintain QoL; avoid abandoning/quick referral/noncommunicative transfer; periodic joint review.
• Primary kidney palliative care comprises of symptom management, diagnose and treat anxiety and depression, communicate.
• Specialty palliative care includes complex/refractory symptoms, conflict resolution, complex psychiatric issues, goals of care.
• The strategies of palliative care are:

o Education of nephrologists on basic level palliative service

o Integrate palliative care with nephrology practice

o Access to specialty palliative services.

• Advanced care planning/shared decision making.

o Should start in CKD 4

o Should be periodically reviewed

o Can include discussion of access and transplant education.

• Should be part of curriculum of DM/DNB/Recognized core competency.