Ethics and Health Policy of Dialyzing a Patient in a Persistent Vegetative State

Abstract

SummaryEach year, out-of-hospital cardiac arrests occur in approximately 300,000 Americans. Of these patients, less than 10% survive. Survivors often live with neurologic impairments that neurologists classify as anoxic-ischemic encephalopathy (AIE). Neurologic impairments under AIE can vary widely, each with unique outcomes. According to the American Academy of Neurology Practice Parameter paper, the definition of poor outcome in AIE includes death, persistent vegetative state (PVS), or severe disability requiring full nursing care 6 months after event. In a recent survey, participants deemed an outcome of PVS as "worse than dead." Lay persons' assessments of quality of life for those in a PVS provide assistance for surrogate decision-makers who are confronted with the clinical decision-making for a loved one in a PVS, whereas clinical practice guidelines help health care providers to make decisions with patients and/or families. In 2000, the Renal Physicians Association and the American Society of Nephrology published a clinical practice guideline, "Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis." In 2010, after advances in research, a second edition of the guideline was published. The updated guideline confirmed the recommendation to withhold or withdraw ongoing dialysis in "patients with irreversible, profound neurological impairments such that they lack signs of thought, sensation, purposeful behavior and awareness of self and environment," such as found in patients with PVS. Here, the authors discuss the applicability of this guideline to patients in a PVS. In addition, they build on the guideline's conception of shared decision-making and discuss how continued dialysis violates ethical and legal principles of care in patients in a PVS.Clin J Am Soc A left heart catheterization with percutaneous intervention to an occluded coronary artery is performed. Anuric renal failure occurs from acute tubular necrosis soon after and dialysis is initiated. He also has complications of postanoxic encephalopathic seizures, lower gastrointestinal bleeding, and laboratory values consistent with shock-liver. He remains intubated without sedation. At both 24 and 72 hours-off sedation-the patient lacks corneal reflexes and has only extensor motor responses to pain. The neurology consultants diagnose him with severe anoxic brain injury and state in the medical record that the patient has a "poor prognosis." Two weeks after arrest, the patient is transferred from the initial hospital to a second hospital at the family's request. At the new hospital, the pulmonary and critical care team consults the neurology, renal, and palliative care teams to discuss the patient's care plan. Dialysis and ventilator support are continued. The primary team schedules a family meeting for the next day with palliative care, patient advocacy, social services, and the patient's wife and two grown children. The meeting centers on discussing the patient as a person, and the medical providers learn that Mr. A. was...

Provision of renal care for patients with end stage kidney disease in persistent vegetative state, in United Arab Emirates: a national survey of renal physicians

“…Thus, provision of regular dialysis treatment to patients in permanent vegetative state who are unaware of self and the surrounding is considered inappropriate [8,20]. When physicians are certain that the dialysis treatment is unlikely to improve the condition or the quality of life, the widely accepted ethical decision is to initiate process of withholding or withdrawing dialysis treatment to relief the patients from the burden of the symptom and the unnecessary dialysis treatment [8,25,26]. .…”

“…Health-care providers have professional responsibility to exercise clinical judgement and guide the family in decision-making by offering medically indicated options that offer a realistic clinical benefit to the patients [8,11]. The new medical liability law (Law No.4 of 2016) published in 15 August 2016, permits health care professionals to refrain from performing CPR on terminally ill or dying patients who are sufferings from incurable illnesses (Federal Law on Medical Liability (Law No.…”

“…However, many patients with ESKD suffer from multiple comorbidities and have high symptom burdens [3–5]. The nephrologists would more often experience decisions of end-of-life renal care with or without dialysis treatment [6–8]. …”

“…Health care policies, available resources, and societal consensus on the management approach would also impact on the clinical decisions of withdrawing or withholding treatment for severely sick patients [8,21–24]. We therefore undertook this survey to explore the renal physicians’ practices of withholding and withdrawal of dialysis treatment during provision of renal care at end-of-life for patients with ESKD in UAE.…”

Four Plus Forty-Four

“…As the evidence against dialysis treatment is growing, so are the questions around appropriateness in certain subgroups (1)(2)(3)(4)(5). Increasingly, studies are showing, particularly in older individuals with a high burden of comorbidity, that patients can do equally well with or without dialysis treatments (6)(7)(8)(9)(10)(11).…”