Kidney Dialysis: Futile Care For Some Nursing Home Residents

Though most of my readers are unlikely to subscribe to the New England Journal of Medicine, Yahoo has done an excellent job in summarizing important issues described in Tumura and Covinsky's original 10/15/09 NEJM article, "Functional Status of Elderly Adults before and after Initiation of Dialysis" (N Engl J Med 361:16).

I read the original article, and Yahoo's summary, with particular interest because a family member chose to end dialysis, and be allowed to die with comfort-only care, when this person's quality of life had severely deteriorated. In my professional life, the issue of  starting or continuing dialysis for elderly nursing home patients has presented several times, and each time I have found the underlying questions troubling.

I will not repeat the summary or further describe Tumura and Consky's article. But I do want to highlight the nature of the decision made to perform dialysis for nursing home patients and the persons who participate in the decision.  Kidney failure in the elderly rarely presents precipitously, unless it results from a medication or procedure known to acutely damage kidneys (i.e., certain antibiotics or x-ray procedures).  As kidney function gradually deteriorates in the elderly, there are often coexisting and contributing serious diseases, such as diabetes, arteriosclerosis, heart disease, and hypertension.  And sometimes there may be age- related dementia or other serious neurologic impairment. The nursing home population, which may be considered for dialysis, is a frail impaired population for which kidney failure is just one of several illnesses which day by day take their increasing toll and in which simply performing the activities of daily living requires trained assistance for the patients.

There may be little or limited conversation between a patient and his primary physicians other than a statement that the doctor has found severe kidney disease and believes it "is time"  to refer the patient to a nephrologist (kidney doctor) and perhaps a vascular dialysis shunt surgeon for consideration of dialysis as a "life-saving" option. In due course the patient is seen by the consultants whose major professional interests and income may revolve around dialysis and the patient, and the patient's family, become convinced to pursue dialysis. Sometimes the patient and family are given full disclosure about the difficulties of performing and maintaining the vascular shunt for dialysis, and sometimes they are not.  Sometimes patients and their families are educated about transportation difficulties,  complications and discomforts associated with dialysis, and sometimes they are not.  Sometimes patients and their families mistakenly believe that dialysis may allow the kidneys to regain function. As the process, initiated in hope, proceeds, patients grow older and more impaired from their complicated medical conditions.

Perhaps a neutral ethicist or "ombudsperson" should be involved early in the decision-making process for all patients to whom chronic dialysis is being offered to evaluate patients' and their families' knowledge and understanding of what is being considered and offered: to perform a reality check with patients, their families, health care surrogates, caregivers, primary care physicians and consultants. If with medical advice, adequate information and understanding, the decision to proceed with dialysis is made, I suggest interval rechecks to verify that the decision remains unchanged rather than proceed unthinkingly simply because dialysis has been initiated.