Time-Limited Trials of Dialysis in the Intensive Care Unit: Are We Timing Dialysis Initiation Appropriately?

Arjun Sekar, MD

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We hope you, the reader, have been pleased with the reintroduction of the Fellows Corner column of Kidney News. Thanks to wonderful leadership from Robert Rope, MD, who has been serving as feature editor, we enjoyed broad participation and believe we have delivered some very informative, poignant, and reflective content. Rob will be stepping down as he completes his third year of fellowship at Stanford and joins the nephrology faculty at Oregon Health & Science University, where he started his medical training. He looks forward to continuing his work with fellows and to bolstering interest in nephrology and education.

We are excited to announce that two terrific contributors will be stepping in as co-editors of Fellows Corner. Please welcome Devika Nair, MD, a fellow at Vanderbilt University, and Daniel Edmonston, MD, a fellow at Duke University. I am confident they will do a terrific job, and together with the rest of the team at Kidney News, look forward to ongoing reader contributions to Fellows Corner in the future.

ASN Kidney News Editor Richard Lafayette, MD

Nephrologists are often consulted for renal replacement therapy (RRT) in critically ill patients in whom the overall prognosis is poor and the benefit of RRT is questionable (mortality in these scenarios is 50% or higher) (1). Initiating RRT can lead to worsened morbidity, extra suffering, and increased health care costs. Time-limited trials (TLTs) in these scenarios offer a potential bridge between conflicted providers or family members.

The “technological imperative” is an imperative of possibility in health care: If it is possible, it has to be done. With the availability of continuous RRT, dialysis can be done more safely, even in critically ill patients. As a consultant in the intensive care unit, the nephrologist often rounds separately, which can lead to fragmented messages delivered to patients and families. Alternatively, the primary team might have already discussed dialysis as a “life-saving” intervention, creating expectations from patients and families. The intensive care unit is a highly stressful environment for families and staff, and fragmented communication can augment difficulties. Within this environment, the technological imperative and cultures of care can mean that starting a patient on dialysis might be easier than withholding it, even when nephrologists might disagree (2).

These scenarios can lead to interprofessional conflict among staff and to clinician unease. Providers’ unexamined emotional responses can lead to burnout, cynicism, frustration, and ultimately, poor patient care (3). I describe some scenarios below where TLTs of dialysis can set clear treatment goals for the primary team and the nephrologist.

When the overall prognosis or clinical benefit of RRT is uncertain, TLTs of dialysis must be considered. TLTs are goal-directed trials of RRT limited by predetermined outcomes evaluated at planned intervals. The emphasis must be on clearly defining and documenting the goals of care with an understanding that the intervention must be stopped if goals are not achieved (4).

There are potential benefits of a TLT of dialysis (5). It allows the nephrologist to assess the reversibility of acute kidney injury, the response to RRT, and changes in the patient’s overall prognosis. TLTs can allow families to come to terms with the guarded prognosis without a sense of abandonment (Tables 1 and 2).

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The guidelines of the Renal Physicians Association on shared decision-making are a useful tool for nephrologists in these ethical situations. There are guidelines specific to the acute setting as well, with step-by-step details on sharing prognosis, communication tools, and TLTs. One very specific recommendation is to offer RRT in critically ill patients when there is ongoing conflict between medical staff and the patient. Dialysis can be provided while pursuing conflict resolution, provided that the patient or legal agent requests it. Physicians familiar with these tools were more comfortable applying these guidelines clinically than those who were not (6).

The decision to initiate RRT in a critically ill patient is tough when the overall prognosis is unclear. Nephrologists in practice and training should familiarize themselves with the Renal Physicians Association guidelines to assist with realistic decision-making and communication with patient surrogates. Establishing clear indications for TLTs in dialysis and studies that assess outcomes, including morbidity, can help us be better at predicting prognosis and communicating with families in these scenarios.

From a personal perspective as a fellow, having these conversations with families and explaining the prognosis helped develop a relationship of trust with the families, which has been very rewarding.

Information in the Clinical Journal of the American Society of Nephrology ethics series (5) can help guide us regarding TLTs in dialysis.

References

1. Kes P, Basic Jukic N. Acute kidney injury in the intensive care unit. Bosn J Basic Med Sci 2010; 10[Suppl 1]:S8–S12.

2. Holley JL. We offer renal replacement therapy to patients who are not benefitted by it. Semin Dial 2016; 29:306–308.

3. Meier DE, Back AL, Morrison RS. The inner life of physicians and care of the seriously ill. JAMA 2001; 286:3007–3014.

4. US President’s Commission. Deciding to Forgo Life-Sustaining Treatment, Washington, DC, 1983.

5. Scherer JS, Holley JL. The role of time-limited trials in dialysis decision making in critically ill patients. Clin J Am Soc Nephrol 2016; 11:344–353.

6. Davison SN, et al. Nephrologists’ reported preparedness for end-of-life decision-making. Clin J Am Soc Nephrol 2006; 1:1256–1262.