This is not a good time for hospital emergency room or intensive care unit director physicians in your communities. If a more severe mutated form of H1N1 ("swine") influenza or a more lethal influenza such as H5N1 (avian) appears, one of these physicians may have to make decisions for which he or she is not likely to be professionally prepared, for which there are no community accepted ethical standards, and which may leave the decider professionally liable for misconduct and exposed to personal financial ruin.
Quietly and without significant current public input or current public ethical discussion , national, state and local public health authorities have assumed the responsibility to order the take-over of public, private and non-profit hospitals, and determining the priorities to be applied when providing life-saving treatments during a national health emergency which swamps the system. As described in The New York Times, 10/25/2009 "Week in Review" section at page 3, the dilemma of "Choosing Who Gets the Breath of Life" and other serious issues of life-saving facility availability will be resolved by government-prescribed triage rules, rather than the rules which govern today's allocation of health care. Who among this blog's readers knows what those triage rules are? Who gave appointed officials the authority to dictate this approach to medical decision-making?
Who among my readers knows which patients will be allowed to continue to receive respirator support and which patients will have that support terminated for the benefit of another person? Who among my readers knows which patients will have dialysis terminated so that another person can have access to the dialysis machine? Who among my readers knows whether, under the triage rules, some older citizens will be removed from life-saving support to benefit those who are younger, what the rules will be on allocation of support among various races, ethnicities, religions, social groups, economic status groups, political members, citizenship groups or occupational groups?
Decisions will have to be made. But having them made by appointed bureaucrats without vigorous current public input and without active current discussion of the ethical issues is inappropriate. The public has the right to participate in this discussion and those with experience and expertise in analyzing and formulating ethical choices and decisions should be heard.
After all, this is America.
Showing posts with label Dialysis. Show all posts
Showing posts with label Dialysis. Show all posts
Sunday, October 25, 2009
Wednesday, October 14, 2009
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.
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.
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