Informed, frank discussion key to dialysis decision

WVU kidney specialist leads group of peers in developing doctors’ guide

MORGANTOWN, W.Va. – No one can dispute the value of dialysis as a life-saving treatment for those whose kidneys can no longer function on their own. Short of transplant surgery, the process is universally viewed as the next best option for prolonging life. However, just as some hopeful kidney recipients can be deemed unsuitable transplant candidates, some older End Stage Renal Disease (ESRD) patients with other existing serious health problems may find dialysis marginally beneficial at best. Alvin H. Moss, M.D., professor in the West Virginia University Section of Nephrology and director of the Center for Health Ethics and Law, chaired the workgroup of the Renal Physicians Association (RPA) that recently updated its the recommendations for doctors treating ESRD patients.

The RPA guide encourages straightforward discussion about the benefits and harms of dialysis treatments. The guidelines for discussion could also be adapted to other serious medical conditions where a positive treatment outcome is highly unlikely. Difficult but necessary questions should be raised, said Dr. Moss. He urges fellow renal physicians to look to the Hippocratic Oath when counseling those over the age of 75 whose kidneys have permanently failed to function about their treatment options.

“The oath states, ‘be of benefit and do no harm,’” Moss said. “We don’t want to put people through a lot of pain and suffering if it’s not going to help them live.”

Since the passage of the 1972 Medicare Reform Act, most ESRD patients whose kidneys have permanently failed to function have received Medicare coverage for dialysis services regardless of age. At the time, there were about 7,000 Americans undergoing dialysis treatment, all between the ages of 20 and 40 with few, if any, co-existing medical issues.

According to the United States Renal Data System 2010 Annual Data Report, of the almost 400,000 patients now on dialysis, 60 percent have diabetes and congestive heart failure, and 80 percent of dialysis patients have high blood pressure. Adjusting for age, sex and race, the risk of death from any cause in dialysis patients is seven times higher than for individuals in the general population. The average survival for a dialysis patient is a little over three years, with about 39 percent surviving five years.

“Kidney specialists are pushing doctors to be more forthright with elderly people who have other serious medical conditions,” Moss said. “It’s up to physicians to tell the patients that even though they are entitled to dialysis, they may want to decline such treatment because of the suffering involved and the fact that they may not live any longer even with dialysis treatments.”

Moss emphasizes that the decision to judge whether or not treatment is appropriate should be based on the patient’s values and overall condition, ultimately resting with the individual and his or her medical caregiver. As uncomfortable as the conversation can be, joint decision-making is proving to have medical benefits of its own.

“Medical treatment is provided one patient at a time in good doctor-patient relationships,” said Moss. “In the last few years, medical research has clearly shown the following benefits of end-of-life discussions by doctors with patients who have a poor prognosis due to advanced cancer or heart, lung, or kidney failure: better patient quality of life, less patient depression, less unwanted aggressive medical care, earlier referral to hospice, lower medical costs and better bereavement adjustment by the family.”

For the RPA’s complete 2010 recommendations, visit www.renalmd.org. To learn more about this and other ethical issues pertaining to healthcare, please visit http://wvethics.org.