TY - JOUR
T1 - The ethics of chronic dialysis for the older patient
T2 - Time to reevaluate the norms
AU - Thorsteinsdottir, Bjorg
AU - Swetz, Keith M.
AU - Albright, Robert C.
N1 - Publisher Copyright:
© 2015 by the American Society of Nephrology.
PY - 2015/11/6
Y1 - 2015/11/6
N2 - Recent research highlights the potential burdens of hemodialysis for older patients with significant comorbidities, for whom there is clinical equipoise regarding the net benefits.With the advent of accountable care and bundled payment, previous incentives to offer hemodialysis to as many patients as possible are being replaced with a disincentive to dialyze high-risk patients. While this may offset the harm of overtreatment for some elderly patients, some voice concerns that the pendulum will swing too far back, with a return to ageist rationing of hemodialysis.Nephrologists should ensure that the patient’s rights to be informed about the potential benefits and burdens of hemodialysis are respected, particularly because age, functional status, nutritional status, and comorbidities affect the net balance between benefits and burdens. Nephrologists are also called on to help patients make a decision, for which the patient’s goals of care guide determination of potential benefit from hemodialysis. This article addresses concerns about present overtreatment and future risk of undertreatment of older adults with ESRD. It also discusses ways in which providers can ethically approach the question of initiation of hemodialysis in the elderly patient by including patient-specific estimates of prognosis, shared decision-making, and the use of specialist palliative care clinicians or ethics consultants for complex cases.
AB - Recent research highlights the potential burdens of hemodialysis for older patients with significant comorbidities, for whom there is clinical equipoise regarding the net benefits.With the advent of accountable care and bundled payment, previous incentives to offer hemodialysis to as many patients as possible are being replaced with a disincentive to dialyze high-risk patients. While this may offset the harm of overtreatment for some elderly patients, some voice concerns that the pendulum will swing too far back, with a return to ageist rationing of hemodialysis.Nephrologists should ensure that the patient’s rights to be informed about the potential benefits and burdens of hemodialysis are respected, particularly because age, functional status, nutritional status, and comorbidities affect the net balance between benefits and burdens. Nephrologists are also called on to help patients make a decision, for which the patient’s goals of care guide determination of potential benefit from hemodialysis. This article addresses concerns about present overtreatment and future risk of undertreatment of older adults with ESRD. It also discusses ways in which providers can ethically approach the question of initiation of hemodialysis in the elderly patient by including patient-specific estimates of prognosis, shared decision-making, and the use of specialist palliative care clinicians or ethics consultants for complex cases.
UR - http://www.scopus.com/inward/record.url?scp=84946750798&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84946750798&partnerID=8YFLogxK
U2 - 10.2215/CJN.09761014
DO - 10.2215/CJN.09761014
M3 - Article
C2 - 25873266
AN - SCOPUS:84946750798
SN - 1555-9041
VL - 10
SP - 2094
EP - 2099
JO - Clinical Journal of the American Society of Nephrology
JF - Clinical Journal of the American Society of Nephrology
IS - 11
ER -