Maximum Conservative Management: A Worthwhile Treatment for Elderly Patients with Renal Failure Who Choose Not to Undergo Dialysis

Burns, Áine; Carson, Rachel C.

doi:10.1089/jpm.2007.0009

Cited by 35 publications

(34 citation statements)

References 3 publications

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“…6,7 In 2011, there were over 1500 patients aged 75 years and over who started RRT in the UK. 4 Several small retrospective or prospective cohort studies have raised the possibility that the balance of benefit versus burden in this older frail group may favour non-dialysis (conservative) management, [6][7][8][9][10][11][12] especially when the patient has a significant burden of morbidity. Those aged 75 years and over with ESKF who have dialysis do have a survival advantage, but this advantage may be small in those with high comorbidity, especially when the effects of establishing access for dialysis, time spent travelling to, receiving and recovering from dialysis three times a week, and complications of dialysis per se, which often result in hospitalisation, are also considered.…”

Section: Chapter 1 Introduction and Backgroundmentioning

confidence: 99%

A national study of practice patterns in UK renal units in the use of dialysis and conservative kidney management to treat people aged 75 years and over with chronic kidney failure

Roderick

Rayner

Tonkin‐Crine

et al. 2015

Health Services and Delivery Research

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BackgroundConservative kidney management (CKM) is recognised as an alternative to dialysis for a significant number of older adults with multimorbid stage 5 chronic kidney disease (CKD5). However, little is known about the way CKM is delivered or how it is perceived.AimTo determine the practice patterns for the CKM of older patients with CKD5, to inform service development and future research.Objectives(1) To describe the differences between renal units in the extent and nature of CKM, (2) to explore how decisions are made about treatment options for older patients with CKD5, (3) to explore clinicians’ willingness to randomise patients with CKD5 to CKM versus dialysis, (4) to describe the interface between renal units and primary care in managing CKD5 and (5) to identify the resources involved and potential costs of CKM.MethodsMixed-methods study. Interviews with 42 patients aged > 75 years with CKD5 and 60 renal unit staff in a purposive sample of nine UK renal units. Interviews informed the design of a survey to assess CKM practice, sent to all 71 UK units. Nineteen general practitioners (GPs) were interviewed concerning the referral of CKD patients to secondary care. We sought laboratory data on new CKD5 patients aged > 75 years to link with the nine renal units’ records to assess referral patterns.ResultsSixty-seven of 71 renal units completed the survey. Although terminology varied, there was general acceptance of the role of CKM. Only 52% of units were able to quantify the number of CKM patients. A wide range reflected varied interpretation of the designation ‘CKM’ by both staff and patients. It is used to characterise a future treatment option as well as non-dialysis care for end-stage kidney failure (i.e. a disease state equivalent to being on dialysis). The number of patients in the latter group on CKM was relatively small (median 8, interquartile range 4.5–22). Patients’ expectations of CKM and dialysis were strongly influenced by renal staff. In a minority of units, CKM was not discussed. When discussed, often only limited information about illness progression was provided. Staff wanted more research into the relative benefits of CKM versus dialysis. There was almost universal support for an observational methodology and a quarter would definitely be willing to participate in a randomised clinical trial, indicating that clinicians placed value on high-quality evidence to inform decision-making. Linked data indicated that most CKD5 patients were known to renal units. GPs expressed a need for guidance on when to refer older multimorbid patients with CKD5 to nephrology care. There was large variation in the scale and model of CKM delivery. In most, the CKM service was integrated within the service for all non-renal replacement therapy CKD5 patients. A few units provided dedicated CKM clinics and some had dedicated, modest funding for CKM.ConclusionsConservative kidney management is accepted across UK renal units but there is much variation in the way it is described and delivered. For best practice, and for CKM to be developed and systematised across all renal units in the UK, we recommend (1) a standard definition and terminology for CKM, (2) research to measure the relative benefits of CKM and dialysis and (3) development of evidence-based staff training and patient education interventions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Chapter 1 Introduction and Backgroundmentioning

confidence: 99%

A national study of practice patterns in UK renal units in the use of dialysis and conservative kidney management to treat people aged 75 years and over with chronic kidney failure

Roderick

Rayner

Tonkin‐Crine

et al. 2015

Health Services and Delivery Research

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“…There is a role for conservative care for those patients with goals of care that are primarily palliative or patients who perceive limited benefit and considerable burden from dialysis (63)(64)(65)(66)(67)(68). This finding is supported by current clinical guidelines (23,25).…”

Section: Acpmentioning

confidence: 92%

“…This finding is supported by current clinical guidelines (23,25). Conservative care focuses on slowing the decline in renal function, actively managing symptoms, using ACP, and providing appropriate palliative care to address patients' goals of care and optimize their quality of life (68). The specifics of facilitating ACP within the context of ESRD have been reviewed recently in this Ethics Series (69) and elsewhere, and therefore, they will not be discussed here (70)(71)(72).…”

Section: Acpmentioning

confidence: 99%

The Ethics of End-of-Life Care for Patients with ESRD

Davison

2012

Clinical Journal of the American Society of Nephrology

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SummaryPatients with ESRD have extensive and unique palliative care needs, often for years before death. The vast majority of patients, however, dies in acute care facilities without accessing palliative care services. High mortality rates along with a substantial burden of physical, psychosocial, and spiritual symptoms and an increasing prevalence of decisions to withhold and stop dialysis all highlight the importance of integrating palliative care into the comprehensive management of ESRD patients. The focus of renal care would then extend to controlling symptoms, communicating prognosis, establishing goals of care, and determining end-of-life care preferences. Regretfully, training in palliative care for nephrology trainees is inadequate. This article will provide a conceptual framework for renal palliative care and describe opportunities for enhancing palliative care for ESRD patients, including improved chronic pain management and advance care planning and a new model for delivering highquality palliative care that includes appropriate consultation with specialist palliative care. To cure sometimes, to relieve often, and to comfort always-this is our work. This is the first and great commandment. And the second is like it. Thou shalt treat thy patient as thou wouldst thyself be treated. AnonymousApproximately 90,000 dialysis patients die each year in the United States, with a high annual unadjusted mortality rate of approximately 20% (1). The exact numbers of patients with ESRD who die without starting dialysis are unknown but estimated to be several fold higher. As of December 31, 2009, there were 397,796 people in the United States on dialysis (1). The prevalent population ages 75 years and older is the largest growing group, having nearly doubled since 1997 (1). Patients with ESRD experience an extremely high burden of symptoms similar to those symptoms of cancer patients hospitalized in palliative care settings (2-8), and they have extensive and unique palliative care needs, often for years before death (9,10). Dialysis patients are more frequently dying after withdrawal of dialysis (10%-15% in 1990 and 20% in 2004) (1), representing the second leading cause of death after cardiovascular disease. Unfortunately, most patients lack decision-making capacity at the time that the decision to withdraw dialysis is made and are not involved in these decisions (11). Most dialysis patients do not have an advance directive and have not had discussions with their family or health providers about their end-of-life care preferences (10), despite patients wanting to engage in these conversations (10,12). Even patients with advance directives often do not address health states in which they would no longer wish to continue dialysis (13,14). Only a minority of patients chooses to forgo cardiopulmonary resuscitation (10,15), because they are unaware of the poor likelihood of survival after cardiopulmonary resuscitation (16). Without advance care planning (ACP), neither family nor physicians is accurate in their predict...

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“…25 The UK Renal Registry does not currently collect data on patients who choose conservative management or who have stable CKD stage V. However, a number of smaller studies have compared outcomes for these patients. 6,21,[27][28][29][30][31][32][33][34] Taken as a whole, patients who choose to dialyse do, generally, live longer that those who choose conservative management, although it does vary quite significantly from study to study, depending in part on definition of conservative management used. However, they also spend much more time in hospital (including dialysis attendances) 28 and frequently report that they are so exhausted after a dialysis session that they cannot even manage to prepare a meal.…”

Section: -24mentioning

confidence: 99%