Conservative care in Europe—nephrologists’ experience with the decision not to start renal replacement therapy

Luijtgaarden, Moniek W.M. van de; Noordzij, Marlies; Biesen, Wim Van; Couchoud, Cécile; Cancarini, Giovanni; Bos, Willem Jan W.; Dekker, Friedo W.; Górriz, José Luis; Iatrou, Christos; Wanner, Christoph; Finne, Patrik; Stojceva-Taneva, Olivera; Čala, Svjetlana; Stel, Vianda S.; Tomson, Charles; Jager, Kitty J.

doi:10.1093/ndt/gft287

Cited by 56 publications

(40 citation statements)

References 24 publications

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“…Nephrologists’ perception regarding dialysis withdrawal is reported twice higher in countries where stopping life-prolonging treatment is allowed [13]. According to these aspects, the results presented here reflect a similar or in part lower utilization of a conservative care approach and rate of dialysis withdrawal compared to European findings [12, 13] with similar legal obligations. In Germany, life-prolonging or life-stopping treatment is allowed only by the consent of a competent patient.…”

Section: Discussionsupporting

confidence: 59%

“…Two-thirds of all addressed centers responded to the questionnaire. This response rate is high in relation to a multi-center European survey [12], but in the same range as a national study from the United Kingdom [18]. Two-thirds of the respondents are men, predominantly in the age group between 44–65 years with long-term experience in renal care.…”

Section: Discussionmentioning

confidence: 89%

“…With respect to European results, significant differences of withholding dialysis are found by comparing for-profit to non-profit centers and low and high-incidence countries [12]. Nephrologists’ perception regarding dialysis withdrawal is reported twice higher in countries where stopping life-prolonging treatment is allowed [13].…”

Section: Discussionmentioning

confidence: 99%

“…Results from an international data base show marked differences in the use, and in part increasing rates, of dialysis discontinuation [10, 11]. European survey results indicated a broad range of conservative treatment utilization between 5 to 20% in countries with different incidence levels of RRT [12]. More recently, a European survey on dialysis withdrawal and palliative care revealed significant differences in practice pattern by profit and non-profit centers, legal regulations, training in and reimbursement of palliative care [13].…”

Section: Introductionmentioning

confidence: 99%

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Conservative Care, Dialysis Withdrawal, and Palliative Care: Results from a Survey of a Non-Profit Dialysis Provider in Germany

Pommer¹,

Wagner²,

Thumfart³

2019

Kidney Blood Press Res

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Background: In Germany, practice patterns of conservative renal care (CRC), dialysis withdrawal (DW), and concomitant palliative care in patients who choose these options are unknown. Method: A survey was designed including 13 structured and one open questions on the management and frequency of CRC and DW, local palliative care structure, and fundamentals of the decision-making process, and addressed to the head physicians of all renal centers (n = 193) of a non-profit renal care provider (KfH – Kuratorium für Dialyse und Nierentransplantation, Neu-Isenburg, Germany). Results: Response rate was 62.2% (n = 122 centers) comprising 14,197 prevalent dialysis patients and 159,652 renal outpatients. Two-thirds of the respondents were men (85% in the age group between 45 and 64 years). Mean time of experience in renal medicine was 22.2 years in men, 20.8 years in women. 94% of all centers provided CRC with a different frequency and proportion of patients (mean 8.4% of the center population, median 5%, range 0–50%). Mean proportion of DW was 2.85% per year (median 2%, range 1–15%). Physicians and center features were not significantly associated with utilization of CRC or DW. Palliative care management varied including local palliative teams, support by general physicians, or by the renal team itself. Hospice care was only established in patients undergoing CRC. Fundamentals of the decision-making process were the desire of the patient (90% in CRC, 67% in DW). Patients undergoing CRC changed their opinion towards treatment modality “frequently” in 18% of the cases, “occasionally” in 73%. Physicians’ decisions were mostly driven by presumed fatal prognosis and poor physical or mental conditions of the individual patient. Different barriers to provide palliative care for the renal population like lack of education in palliative medicine, shortness of staff, lack of financial resources, and local palliative care structures were reported. Conclusion: Compared to international numbers, in Germany, proportion of CRC and DW reported by non-profit renal centers is in the lower range. Center practice of palliative care management varies and is driven by availability of local palliative care resources and presumably by attitudes of the renal teams. Quality of palliative care and the decision-making process need further evaluation.

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Section: Discussionsupporting

confidence: 59%

Section: Discussionmentioning

confidence: 89%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Conservative Care, Dialysis Withdrawal, and Palliative Care: Results from a Survey of a Non-Profit Dialysis Provider in Germany

Pommer¹,

Wagner²,

Thumfart³

2019

Kidney Blood Press Res

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“…Starting dialysis was associated with a substantial and sustained decline in functional status among nursing home residents (3), and RRT may not be beneficial in the context of increasing frailty and loss of independence (4)(5)(6). A conservative care pathway is increasingly recognized as an alternative treatment to dialysis and has been introduced in the United Kingdom (UK) (1,(6)(7)(8)(9)(10), Australia (11,12), other European countries (13)(14)(15), and Asia (16)(17)(18).…”

Section: Introductionmentioning

confidence: 99%

Conservative Care for ESRD in the United Kingdom

Okamoto

Tonkin‐Crine

Rayner

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives Conservative kidney management (CKM) has been developed in the United Kingdom (UK) as an alternative to dialysis for older patients with stage 5 CKD (CKD5) and multiple comorbidities. This national survey sought to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development.Design, setting, participants, & measurements A survey on practice patterns of CKM for patients age 75 and older with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013.Results Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although "conservative management" was the most frequently used term (46%). Lack of an agreed-upon definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. Fifty-two percent provided the number of CKM patients age $75 years in 2012; the median was 45 per unit (interquartile range [IQR], 20-83). The median number of symptomatic CKM patients who would otherwise have started dialysis was eight (IQR,. CKM practice patterns varied: 35% had a written guideline, 23% had dedicated CKM clinics, 45% had dedicated staff, and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. Eighty percent identified a need for better evidence comparing outcomes on CKM versus dialysis, and 65% considered it appropriate to enter patients into a randomized trial.Conclusions CKM is provided in almost all UK renal units, but scale and organization vary widely. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support for further research comparing outcomes with conservative care versus dialysis.

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Dialysis Versus Conservative Care in the Elderly: Making a Choice

Burns

2015

Dialysis in Older Adults

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Conservative care in Europe—nephrologists’ experience with the decision not to start renal replacement therapy

Cited by 56 publications

References 24 publications

Conservative Care, Dialysis Withdrawal, and Palliative Care: Results from a Survey of a Non-Profit Dialysis Provider in Germany

Conservative Care, Dialysis Withdrawal, and Palliative Care: Results from a Survey of a Non-Profit Dialysis Provider in Germany

Conservative Care for ESRD in the United Kingdom

Dialysis Versus Conservative Care in the Elderly: Making a Choice

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