The strange case of Mr. H. Starting dialysis at 90 years of age: clinical choices impact on ethical decisions

Abstract

BackgroundStarting dialysis at an advanced age is a clinical challenge and an ethical dilemma. The advantages of starting dialysis at “extreme” ages are questionable as high dialysis-related morbidity induces a reflection on the cost- benefit ratio of this demanding and expensive treatment in a person that has a short life expectancy. Where clinical advantages are doubtful, ethical analysis can help us reach decisions and find adapted solutions.Case presentationMr. H is a ninety-year-old patient with end-stage kidney disease that is no longer manageable with conservative care, in spite of optimal nutritional management, good blood pressure control and strict clinical and metabolic evaluations; dialysis is the next step, but its morbidity is challenging. The case is analysed according to principlism (beneficence, non-maleficence, justice and respect for autonomy).In the setting of care, dialysis is available without restriction; therefore the principle of justice only partially applied, in the absence of restraints on health-care expenditure. The final decision on whether or not to start dialysis rested with Mr. H (respect for autonomy). However, his choice depended on the balance between beneficence and non-maleficence. The advantages of dialysis in restoring metabolic equilibrium were clear, and the expected negative effects of dialysis were therefore decisive. Mr. H has a contraindication to peritoneal dialysis (severe arthritis impairing self-performance) and felt performing it with nursing help would be intrusive. Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily life of haemodialysis patients are closely linked to the classic thrice-weekly, four-hour schedule. A personalized incremental dialysis approach, starting with one session per week, adapting the timing to the patient’s daily life, can limit side effects and “dialysis shock”.ConclusionsAn individualized approach to complex decisions such as dialysis start can alter the delicate benefit/side-effect balance, ultimately affecting the patient’s choice, and points to a narrative, tailor-made approach as an alternative to therapeutic nihilism, in very old and fragile patients.

Patient privacy and autonomy: a comparative analysis of cases of ethical dilemmas in China and the United States

“…Despite there has been controversies and challenges in relation to the four principles of bioethics—respect for autonomy, non-maleficence, beneficence, and justice—respect for the patient’s autonomy is usually considered to be an important principle in Western countries [ 5 , 6 ]. To respect the autonomy of agents represents an acknowledgement of their right to hold views, make choices, and take actions based on their values and beliefs [ 7 ].…”

Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach

“…When nephroangiosclerosis and diabetes-rather than pyelonephritis and glomerulonephritiscame to be seen as the causes of end-stage renal disease (ESRD), this was not without consequences for dialysis tolerance, and the first caveats on eating during dialysis date to this phase. The progressive shortening of dialysis time, made possible by increased dialysis efficiency, occurred at the same time as the dialysis population started to become progressively older, a process that is continuing, at least in many European settings [57][58][59][60][61][62].…”

Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status

“…Attaining efficient depuration, controlled by the classic kinetic markers, may not be sufficient in all patients, and may not be the priority in the present elderly and high-comorbidity dialysis population [ 19 , 20 , 21 , 22 , 23 ]. Prescription of all treatments, including dialysis, should first of all comply with the imperative “do no harm” [ 24 , 25 , 26 ]. The high mortality on initiation of dialysis, recently termed “dialysis shock” and the lack of advantages (and possible disadvantages) of early versus late dialysis initiation, together with the contrasting results of dialysis or supportive treatment in the elderly, indicate that dialysis saves lives, but not without cost [ 27 , 28 , 29 , 30 , 31 , 32 , 33 ].…”