Choices for Dialysis Patients at the End of Life

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When kidney dialysis was introduced in the 1940s it was originally intended as a life saving treatment.  It was mainly used for young patients with acute renal failure and helped them until their kidneys could function without the therapy.  Since then the use and frequency of dialysis has changed.  Today the average dialysis patient is 65 years old and is used as a maintenance treatment just as often as it is for acute episodes.

There are some medical professionals that believe dialysis is simply prolonging an inevitable conclusion of this patient population: death.  “Many of these patients don’t realize they are in the final phase of life because no one has talked forthrightly with them,” said Mildred Z. Solomon, EdD, president of The Hastings Center. A 2013 analysis published in the Journal of General Internal Medicine (2013;28:1511-1516) found that patients with end stage renal disease (ESRD) reported they did not know their medical prognosis and couldn’t recall being offered dialysis alternatives.  Another report in Medical Anthropology Quarterly (2005;24:297-324), found that of all the patients researchers spoke with at two Californian dialysis clinics, only 4 confirmed they initiated dialysis treatments by choice.

Give People a Choice, It Might Be Their Last Chance to Make One

There is a growing movement of physicians and bioethics organizations that believe such patients should be given more information about their illness and more choices about how they want to spend their final years alive.  “We haven’t had a grown-up conversation that this is a stage of life patients are in and death may not be that far away,” Dr. Solomon said. “People want to have that sort of conversation and are expecting it from their doctors, but physicians aren’t initiating it.”  Patients are surrounded by medical staff all the time, including nurses and dialysis technicians.  But these staff are not necessarily trained or equipped to have these types of conversations with patients.  It’s important that the primary physicians and specialists step up and take lead.

It’s a difficult job, but somebody has to be straightforward with patients and give them the choice of how they want to end their lives.  “Everything we know about patients suggests that most of them want to have the conversation,” said Lewis Cohen, MD, professor of psychology at Tufts School of Medicine in Boston. “And patients want doctors to be the ones to broach the subject.”  Dr. Cohen recommended the following guidelines for having such a conversation with ESRD patients:

  • Identify patient preferences. What kind of care do they want? Who should speak with them if they are unable to communicate?
  • Ascertain if the patient is even willing to hear about dialysis alternatives.
  • Ascertain what the patient already knows about their medical condition. Many patients want to get the issue of death out in the open and would rather have the discussion with medical professionals than family or friends.
  • Provide as much information to patients as possible.
  • Give the patient a specific estimate of prognosis.
  • Inquire about the patient’s goals and expectations of treatment.

Patients should hear about their options and receive thorough thoughtful recommendations from practitioners.  By exploring their thoughts, beliefs, ideas and expectations, you can help dialysis patients make the best choices for their unique situation.

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