When Enough Is Enough: The Nephrologist's Responsibility in Ordering Dialysis Treatments

Michael J. Germain, MD; Sara N. Davison, MD; Alvin H. Moss, MD

Disclosures

Am J Kidney Dis. 2011;58(1):135-143. 

In This Article

Abstract and Introduction

Abstract

For more than 20 years, nephrologists have been reporting that they are increasingly being expected to dialyze patients whom they believe may receive little benefit from dialysis therapy. During this time, there has been substantial research about the outcomes of patients of differing ages and comorbid conditions requiring dialysis and the development of clinical practice guidelines for dialysis decision making based on research evidence, ethics, and the law. The importance of palliative medicine to the care of the patient throughout the continuum of kidney disease also has been recognized, and its application has been described. This article summarizes these advances and provides an approach for decision making and treatment for patients who are not likely to benefit from dialysis therapy.

Introduction

International data show extremely high mortality in elderly patients initiating dialysis therapy, with the highest mortality rates in the United States and Australia/New Zealand.[3] Although there are many possible causes for this, an important contributor is the increasing number of elderly patients with severe chronic illnesses initiating dialysis therapy in these countries. Importantly, the trend in many other countries is similar. Poor 6-month survival in this population is common and multifactorial in origin. In some cases, patients already may be in the active dying process and dialysis may not alter this trajectory. Furthermore, it is possible that the dialysis procedure itself or vascular access may contribute to the poor outcome due to adverse effects on the heart, access-related infections, and accelerated loss of residual kidney function. Notably, patients residing in long-term care facilities at the time of dialysis therapy initiation have an especially poor outcome,[4] with poor survival and poor quality of life. Although elderly patients have been starting dialysis therapy at higher GFRs, recent studies, including the IDEAL (Initiating Dialysis Early and Late) randomized controlled trial, show no benefit to an early start.[5] Rosansky et al[6] have suggested that the severity of CKD may be overdiagnosed in the elderly based on inaccuracies in eGFR measures, and this may result in unnecessary dialysis therapy initiation. In the Veterans Administration population, O'Hare et al[7] showed that elderly patients may have slower progression to ESRD, with most elderly patients, even at the lowest eGFRs, more likely to die than progress to ESRD. This issue of competing risk between kidney failure and mortality becomes more notable as the population ages, with <1% of elderly patients with CKD progressing to kidney failure and subsequent dialysis each year.[8–12]

It is suggested that elderly patients will benefit from an integrated individual approach to care that focuses on attainment of patient goals, relief of suffering, preservation of functional status, and maximizing quality of life rather than the traditional disease approach. In the former model of care, patients' symptoms and function are the primary focus, rather than survival.[9,13] A number of reports now have shown that elderly patients with comorbid conditions can be managed using active medical management without dialysis (called conservative management). Patients managed in this fashion may live as long as patients who elect to start dialysis therapy, with more days spent outside the dialysis unit or hospital[14–21] (Fig 1).

Figure 1.

Survival in elderly patients with chronic kidney disease stage 5. Kaplan-Meier survival curves for those with high comorbidity (score, 2) comparing dialysis and conservative groups (log rank statistic <0.001; df, 1; P = 0.98). Abbreviation: eGFR, estimated glomerular filtration rate. Reproduced from Murtagh et al14 with permission of the European Renal Association–European Dialysis and Transplant Association.

The shared-decision-making model has been promoted as the best way to balance patient and/or family concerns with the clinician's goals for treatment. Too often, clinicians offer patients a list of options without providing their expert opinion about what might be the best choice. At the other extreme, invasive care, such as dialysis, often is assumed to be the only option without discussion of other less invasive options (paternalistic). The shared-decision-making model provides a collaborative approach that leads to a consensus decision. The present case describes a patient who is likely to derive more benefit from active medical management without dialysis than by initiating dialysis therapy. In this article, we discuss the ethical, social, and cultural issues surrounding withholding and withdrawal of dialysis therapy and how prognosis and treatment plans can be discussed and communicated with the patient and family.

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