A Communication Framework for Dialysis Decision-Making for Frail Elderly Patients

Schell, Jane O.; Cohen, Robert A.

doi:10.2215/cjn.02190314

Cited by 56 publications

(40 citation statements)

References 36 publications

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“…If given the choice before an emergent situation occurs, some of these patients may choose conservative management, [Table 1], [17, 20, 21, 57, 58]. Others may opt for a time limited trial of dialysis [59].…”

Section: Main Textmentioning

confidence: 99%

Treatment decisions for older adults with advanced chronic kidney disease

Rosansky

Schell

Shega³

et al. 2017

BMC Nephrol

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Dialysis initiation rates among older adults, aged 75 years or greater, are increasing at a faster rate than for younger age groups. Older adults with advanced CKD (eGFR < 30 ml/min/1.73 m2) typically lose renal function slowly, often suffer from significant comorbidity and thus may die from associated comorbidities before they require dialysis.A patient’s pattern of renal function loss over time in relation to their underlying comorbidities can serve as a guide to the probability of a future dialysis requirement. Most who start dialysis, initiate treatment “early”, at an estimated glomerulofiltration rate (eGFR) >10 ml/min/1.73 m2 and many initiate dialysis in hospital, often in association with an episode of acute renal failure. In the US older adults start dialysis at a mean e GFR of 12.6 ml/min/1.73 m2 and 20.6% die within six months of dialysis initiation. In both the acute in hospital and outpatient settings, many older adults appear to be initiating dialysis for non-specific, non-life threatening symptoms and clinical contexts. Observational data suggests that dialysis does not provide a survival benefit for older adults with poor mobility and high levels of comorbidity. To optimize the care of this population, early and repeat shared decision making conversations by health care providers, patients, and their families should consider the risks, burdens, and benefits of dialysis versus conservative management, as well as the patient specific symptoms and clinical situations that could justify dialysis initiation. The potential advantages and disadvantages of dialysis therapy should be considered in conjunction with each patient’s unique goals and priorities.In conclusion, when considering the morbidity and quality of life impact associated with dialysis, many older adults may prefer to delay dialysis until there is a definitive indication or may opt for conservative management without dialysis. This approach can incorporate all CKD treatments other than dialysis, provide psychosocial and spiritual support and active symptom management and may also incorporate a palliative care approach with less medical monitoring of lab parameters and more focus on the use of drug therapies directed to relief of a patient’s symptoms.

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Section: Main Textmentioning

confidence: 99%

Treatment decisions for older adults with advanced chronic kidney disease

Rosansky

Schell

Shega³

et al. 2017

BMC Nephrol

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“…They are asked to use the RPA Shared Decision Making Toolkit, after reading selected papers in the area [1–3, 6, 7]. Our survey methodology does not permit direct conclusions about the effectiveness of this education, but comparison of responses between more recent graduates and those with longer practice experience may provide some insight.…”

Section: Discussionmentioning

confidence: 99%

An end-of-life practice survey among clinical nephrologists associated with a single nephrology fellowship training program

Ceckowski

Little

Merighi

et al. 2017

Clinical Kidney Journal

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BackgroundOur nephrology fellowship requires specific training in recognition and referral of end-stage renal disease patients likely to benefit from palliative and hospice care.MethodsTo identify end-of-life (EOL) referral barriers that require greater training emphasis, we performed a cross-sectional, 17-item anonymous online survey (August–October 2015) of 93 nephrologists associated with the program since 1987.ResultsThere was a 61% response rate (57/93 surveys). Ninety-five percent practiced clinical nephrology (54/57). Of these, 51 completed the survey (55% completion rate), and their responses were analyzed. Sixty-four percent were in practice >10 years; 65% resided in the Southern USA. Ninety-two percent felt comfortable discussing EOL care, with no significant difference between those with ≤10 versus >10 years of practice experience (P = 0.28). Thirty-one percent reported referring patients to EOL care ‘somewhat’ or ‘much less often’ than indicated. The most frequent referral barriers were: time-consuming nature of EOL discussions (27%); difficulty in accurately determining prognosis for <6-month survival (35%); patient (63%) and family (71%) unwillingness; and patient (69%) and family (73%) misconceptions. Fifty-seven percent would refer more patients if dialysis or ultrafiltration could be performed in hospice. Some reported that local palliative care resources (12%) and hospice resources (6%) were insufficient.ConclusionsThe clinical nephrologists surveyed were comfortable with EOL care discussion and referral. Patient, family, prognostic and system barriers exist, and many reported lower than indicated referral rates. Additional efforts, including, but not limited to, EOL training during fellowship, are needed to overcome familial and structural barriers to facilitate nephrologist referral for EOL care.

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“…As illustrated in Figure 1, the time limits chosen are dependent on the etiology of AKI and the patient's overall prognosis and should be flexible as the clinical scenario evolves. Each reassessment serves as a pause point for reflection of the burdens and benefits of dialysis within the developing clinical situation (8). Although TLTs for AKI can last weeks, it is appropriate to arrange for a planned reassessment within days of CRRT initiation given the dynamic nature of critical illness, subsequent changing goals of care, and involvement of multiple medical providers.…”

Section: Identification Of the Ethical Questions At Handmentioning

confidence: 99%

The Role of Time–Limited Trials in Dialysis Decision Making in Critically Ill Patients

Scherer

Holley

2016

Clinical Journal of the American Society of Nephrology

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Technologic advances, such as continuous RRT, provide lifesaving therapy for many patients. AKI in the critically ill patient, a fatal diagnosis in the past, is now often a survivable condition. Dialysis decision making for the critically ill patient with AKI is complex. What was once a question solely of survival now is nuanced by an individual's definition of quality of life, personal values, and short-and long-term prognoses. Clinical evaluation of AKI in the critically ill is multifaceted. Treatment decision making requires consideration of the natural evolution of the patient's AKI within the context of the global prognosis. Situations are often marked by prognostic uncertainty and clinical unknowns. In the face of these uncertainties, establishment of patient-directed therapies is imperative. A time-limited trial of continuous RRT in this setting is often appropriate but difficult to execute. Using patient preferences as a clinical guide, a proper time-limited trial requires assessment of prognosis, elicitation of patient values, strong communication skills, clear documentation, and often, appropriate integration of palliative care services. A well conducted time-limited trial can avoid interprofessional conflict and provide support for the patient, family, and staff.

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A Communication Framework for Dialysis Decision-Making for Frail Elderly Patients

Cited by 56 publications

References 36 publications

Treatment decisions for older adults with advanced chronic kidney disease

Treatment decisions for older adults with advanced chronic kidney disease

An end-of-life practice survey among clinical nephrologists associated with a single nephrology fellowship training program

The Role of Time–Limited Trials in Dialysis Decision Making in Critically Ill Patients

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