Withholding or withdrawing dialysis in the elderly: the perspective of a western region of France

Clément, Renaud; Chevalet, P.; Rodat, O.; Ould-Aoudia, Vincent; Berger, Michel

doi:10.1093/ndt/gfi012

Cited by 17 publications

(12 citation statements)

References 19 publications

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“…However, it is not clear that CM is adequately discussed as a viable treatment option in the United States (12,13). Reasons for this may include providers' uncertainty about patient prognosis, a relative lack of evidence of its efficacy compared with dialysis, and providers' personal values, which may prioritize survival over quality of life (14)(15)(16).…”

Section: Introductionmentioning

confidence: 99%

Provider Knowledge, Attitudes, and Practices Surrounding Conservative Management for Patients with Advanced CKD

Parvez

Abdel-Kader

Pankratz

et al. 2016

CJASN

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Background and objectives Despite the potential benefits of conservative management, providers rarely discuss it as a viable treatment option for patients with advanced CKD. This survey was to describe the knowledge, attitudes, and practices of nephrologists and primary care providers regarding conservative management for patients with advanced CKD in the United States.Design, setting, participants, & measurements We developed a questionnaire on the basis of a literature review to include items assessing knowledge, attitudes, and self-reported practices of conservative management for patients with advanced CKD. Potential participants were identified using the American Medical Association Physician Masterfile. We then conducted a web-based survey between April and May of 2015.Results In total, 431 (67.6% nephrologists and 32.4% primary care providers) providers completed the survey for a crude response rate of 2.7%. The respondents were generally white, men, and in their 30s and 40s. Most primary care provider (83.5%) and nephrology (78.2%) respondents reported that they were likely to discuss conservative management with their older patients with advanced CKD. Self-reported number of patients managed conservatively was .11 patients for 30.6% of nephrologists and 49.2% of primary care providers. Nephrologists were more likely to endorse difficulty determining whether a patient with CKD would benefit from conservative management (52.8% versus 36.2% of primary care providers), whereas primary care providers were more likely to endorse limited information on effectiveness (49.6% versus 24.5% of nephrologists) and difficulty determining eligibility for conservative management (42.5% versus 14.3% of nephrologists). There were also significant differences in knowledge between the groups, with primary care providers reporting more uncertainty about relative survival rates with conservative management compared with different patient groups.Conclusions Both nephrologists and primary care providers reported being comfortable with discussing conservative management with their patients. However, both provider groups identified lack of United States data on outcomes of conservative management and characteristics of patients who would benefit from conservative management as barriers to recommending conservative management in practice.

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Section: Introductionmentioning

confidence: 99%

Provider Knowledge, Attitudes, and Practices Surrounding Conservative Management for Patients with Advanced CKD

Parvez

Abdel-Kader

Pankratz

et al. 2016

CJASN

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“…The thought of making the ‘wrong decision’ haunts every clinician and studies of physicians’ attitudes show that individual physician comfort with recommending against dialysis varies both with age and experience [21]. Interestingly, a substantial number of physicians surveyed expressed regret over one or more previous decisions to offer or withhold dialysis.…”

Section: Patient Selectionmentioning

confidence: 99%

Non-Dialysis Care: An Important Component of Care for Elderly Individuals with Advanced Stages of Chronic Kidney Disease

Jassal

Kelman

Watson³

2011

Nephron Clin Pract

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Non-dialysis care (NDC) is the provision of all aspects of renal care except for the dialysis process. While the nomenclature may vary, with terms such as ‘conservative care’, ‘maximal conservative management’ or ‘non-dialytic treatment’ having been associated with NDC, the clinical principle is to provide comprehensive care to patients who opt to forgo dialysis despite increasing uraemic symptoms. NDC therapies focus on pain relief, the use of erythropoietin-stimulating agents, anti-pruritics and anti-nausea therapies, with lower emphasis on strategies used to modulate the rate of renal progression. Patient selection remains the most challenging aspect of developing an NDC program, with selection often being based on physician instinct, family principles and population-based prognostic risk measures. Outcomes are fair with a significant proportion of NDC patients experiencing lower hospitalization days and higher rates of death at home (or in a preferred environment) rather than in acute-care hospitals.

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“…[17][18][19] Patient variables including age, functional status, socioeconomic status, and preferences have been shown to be associated with physician decisions. 22,26 In several of these studies, patient age is a factor in decisions to withhold dialysis (i.e., increasing age associated with greater likelihood to withhold dialysis). [18][19][20][21][22][23][24][25][26][27] Retrospective studies of dialysis patients have also found patient variables to be important.…”

Section: Referral Decisions For Dialysis Initiationmentioning

confidence: 99%

Older Adults and Chronic Kidney Disease Decision Making by Primary Care Physicians: A Scholarly Review and Research Agenda

et al. 2008

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BACKGROUND: Chronic kidney disease (CKD) is a growing public health concern that overwhelmingly affects older adults. National guidelines have called for earlier referral of CKD patients, but it is unclear how these should apply to older adults.OBJECTIVE: This scholarly review aims to explore the current literature about upstream referral decisions for CKD within the context of decisions about initiation of dialysis and general referral decisions. The authors propose a model for understanding the referral process and discuss future directions for research to guide decision making for older patients with CKD. RESULTS:While age has been shown to be influential in decisions to refer patients for dialysis and other medical therapies, the role of other patient factors such as competing medical co-morbidities, functional loss, or cognitive impairment in the decision making of physicians has been less well elucidated, particularly for CKD. CONCLUSIONS:More information is needed on the decision-making behavior of physicians for upstream referral decisions like those being advocated for CKD. Exploring the role of geriatric factors like cognitive and functional status may help facilitate more appropriate use of resources and improve patient outcomes.KEY WORDS: chronic kidney disease; decision making; older adults.

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Withholding or withdrawing dialysis in the elderly: the perspective of a western region of France

Cited by 17 publications

References 19 publications

Provider Knowledge, Attitudes, and Practices Surrounding Conservative Management for Patients with Advanced CKD

Provider Knowledge, Attitudes, and Practices Surrounding Conservative Management for Patients with Advanced CKD

Non-Dialysis Care: An Important Component of Care for Elderly Individuals with Advanced Stages of Chronic Kidney Disease

Older Adults and Chronic Kidney Disease Decision Making by Primary Care Physicians: A Scholarly Review and Research Agenda

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