Effects of a Transitional Palliative Care Model on Patients With End-stage Renal Failure

Inclusion Criteria: * Patient with chronic kidney disease and diabetic mellitus with Creatinine ≥350 milli mole (uM) or those without diabetic mellitus with Creatinine ≥450 milli mole (uM) who refused renal replacement therapy (RRT); * Patient not suitable for long term renal replacement therapy (RRT) after assessment by renal team (e.g. multiple co morbidities, poor functional status and social support) * Identified as ESRF patient eligible for palliative care without prior renal replacement therapy * Ability to speak Cantonese * Living within the hospital service area * Ability to be contacted by phone Exclusion Criteria: * Discharged to nursing home or other institution * Inability to communicate * Cognitive impairment, mini mental stage examination (MMSE) \< 20 * Diagnosed with severe psychiatric disorders such as schizophrenia and bipolar disorder