Should Dialysis be Offered to All Elderly Patients?

Abstract

Nephrologist are often faced with the question of the appropriate initiation and withdrawal from dialysis. Many clinicians feel that patient should be offered dialysis when they have ESRD regardless of the potential risks vs. benefits. My position in this debate is that nephrologists have the obligation to order treatments that are indicated and effective for their patients and will provide more benefit that harm. They should not order dialysis in patient that are not likely to benefit from the treatment. Patients have the right to refuse treatments but not the right to demand that a clinician order an ineffective treatment. Shared decision making is the key principle in deciding on the initiation and withdrawal from dialysis. The national guideline; Shared Decision Making: The Appropriate Initiation and Withdrawal from Dialysis supports this approach.

Factors Associated With Withdrawal From Dialysis Therapy in Incident Hemodialysis Patients Aged 80 Years or Older

“…5,14 While dialysis treatment may prolong the survival of the very-elderly ESRD population, 3,15,16 there remains wide debate as to whether dialysis treatment vs. conservative strategies offer greater benefit with respect to patient-centered outcomes such as quality of life in this population. [17][18][19][20] Given their complex comorbidities and unique physical and mental/ cognitive health profiles, further studies are needed to determine optimal management strategies informed by outcomes as well as patient preferences among the very-elderly ESRD population. As epidemiologic data have shown a rising frequency in patient-driven cessation from dialysis (e.g., withdrawal) over the past three decades 21,22 particularly amongst patients of older age, 23 we sought to determine the impact of withdrawal from dialysis upon outcomes of very-elderly hemodialysis patients, as well as factors (patient vs. non-patient driven) associated with withdrawal from dialysis in this population.…”

Hospital Utilization and Costs in Older Patients with Advanced Chronic Kidney Disease Choosing Conservative Care or Dialysis: A Retrospective Cohort Study

“…Older patients represent the fastest growing group. In older patients, dialysis has become the most common treatment for end-stage kidney disease, but some might consider dialysis as too burdensome outweighing its benefits [3,4]. Nondialytic conservative care has been recognized as a viable alternative, which aims to preserve quality of life by active medical treatment and multidisciplinary care including all interventions as needed although without dialysis [5][6][7].…”

Dialysis in the Elderly and Impact of Institutionalization in the United States Renal Data System

“…Some suggestion has been made for later initiation of dialysis in the elderly and the use of palliative measures to improve their quality of life [9]. Overall, there is little data showing the benefit of renal replacement therapy in those over 85 years [12,13]. Given the lack of consensus as to how to approach the very elderly in need for dialysis, approaches relevant to each individual have been suggested [14].…”