Acute Kidney Injury in Critical Patients and the Role of Palliative Care

Offering patients life-prolonging treatments while at the same time improving their quality of life is a balancing act. With time, we learn that more care is not necessarily good care, that not every test or treatment available to the patient is needed, and that, at times, they may cause more harm than good.

A clinician must judge which treatment is quantitatively futile (it simply cannot physiologically work) or inappropriate. The latter is a gray zone and at times takes into consideration the clinicians’, patients’, and surrogates’ personal conceptions about life and treatment goals. One such treatment is dialysis in a critically ill patient with acute kidney injury (AKI). Critically ill patients with AKI have a high mortality; of the 490 patients who required dialysis in the SUPPORT Trial (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments), only 27% survived after 5 months (1). Furthermore, dialysis was not shown to be cost effective in this population. Withholding or withdrawing a potentially inappropriate treatment in a critical patient can be particularly challenging, especially in an intensive care unit (ICU), where intense plans of support may be in place, indicating patients’ or their families’ unrealistic expectations of survival or quality of life. At times, other health care professionals may be in the same boat. What is then the best way to have these complex conversations with doctors, patients, and their families? Where do we start?

We must first equip ourselves with the knowledge of why and when we need to withdraw or withhold dialysis in a critically ill patient with AKI. Several factors make this clinical scenario more complicated than withholding dialysis in an ESRD patient: most of the patients in the ICU are incapacitated, surrogate decision-makers may not have a clear understanding of the goals of treatment and prognosis, and the reversible nature of the injury may bring up the option of temporary dialysis.

/kidneynews/9_9/14/graphic/14f1.jpg

In 2000, the Renal Physicians Association (RPA) and the American Society of Nephrology (ASN) published a clinical practice guideline: “Shared decision-making in the appropriate initiation and withdrawal from dialysis. The Renal Physicians Association and the American Society of Nephrology” (2). Its goal was to provide evidence-based guidelines for clinical decision-making that can be tailored to a specific patient or situation. The nine recommendations include shared decision-making, informed consent or refusal of all available treatment options (including temporary dialysis), estimating prognosis, conflict resolution (between nephrologist and patient or other health care providers), advance directives, withholding or withdrawing dialysis, special patient groups (those with terminal illness due to nonrenal cause), time-limited trials of dialysis (if prognosis is uncertain), and palliative care (for those who forego dialysis). Addressing these nine factors can help physicians and patients reach an informed and ethical shared decision about initiating versus withholding or withdrawing dialysis.

Shared decision-making involves providing clear information about the risks and benefits of each treatment. The Choosing Wisely campaign, an initiative of the American Board of Internal Medicine, is intended to identify situations where the need for certain tests and treatment is questioned by encouraging open communication between physicians and patients (3). As part of this campaign, ASN has published guidelines about shared decision-making for chronic dialysis. There are modules that provide guidance to physicians about efficient patient communication. Per these recommendations, the four key interactional components that lead to better outcomes include “providing clear information; [c]reating mutually agreed upon goals for care; [p]atients taking an active role in their care; and [p]hysicians providing encouragement, empathy and praise” (3). We may apply the same communication strategies to discussions about dialysis for AKI in critical patients. We must be mindful that care in the ICU can often be challenging in terms of communication because oftentimes patients are debilitated and are not able to be fully involved in their care; therefore, we tend to have these conversations with surrogate decision-makers. Problems arise when there is poor communication regarding treatment goals, which should be an ongoing dialogue.

The expected outcome for and prognosis of critically ill patients with AKI should be addressed when making decisions pertaining to dialysis. As outlined in the RPA/ASN guidelines, it is reasonable to withdraw or withhold dialysis in patients facing terminal illness (life expectancy of 6 months or less secondary to nonrenal cause) who are not transplant candidates. These patients may include those with advanced malignancy not amenable to treatment, severe cirrhosis, heart failure, or end stage pulmonary disease. In other situations, criteria for the risk of renal failure, injury to the kidney, failure of kidney function, loss of kidney function, and end stage renal failure may be used to evaluate management and expected outcome (4). A prospective study performed in 2008 found six of the prognostic tools to be inaccurate in predicting hospital mortality or need for renal replacement therapy in ICU patients with AKI (5). Few studies have evaluated the long-term outcomes and quality of life of survivors. When the outcome is uncertain, patients may be offered time-limited trials of dialysis with a goal to withdraw dialysis if it does not provide benefit in the specified time. Objective ways to measure short-term benefit may include electrolytes and BUN.

Physicians who see chronic kidney disease patients in a non-ICU setting should discuss and document patients’ wishes about initiating dialysis if they are likely to develop AKI during a hospitalization. In an ICU, patients who have decision-making capacity and refuse dialysis or have advance directives or appointed surrogates who concur should have their choices respected, and dialysis should not be initiated. On the other hand, some patients or their families may insist on dialysis even after it is considered quantitatively or qualitatively futile (e.g., a time-limited trial of dialysis is unsuccessful). This may pose an ethical and legal issue. Informed decision-making is an integral component when considering the legality of withholding or withdrawing dialysis; therefore, all discussions need to be documented. Because this is a shared decision-making process, involving a palliative care team or requesting an ethics committee consultation may be helpful to resolve conflicts between the provider and the patient.

In conclusion, taking care of critically ill patients can be challenging. Open communication with other caregivers, patients, and their families is an essential component of providing care and forms the basis of a strong relationship. Offering comprehensive care in a complex setting requires addressing a patient’s prognosis, good clinical judgment about utilization of appropriate treatment options, adequate training of physicians in relevant communication skills, and ongoing collaboration with palliative care teams, as well as with patients and their families.

"September 2017 (Vol. 9, Number 9)"

References

1. Hamel MB, et al. Outcomes and cost-effectiveness of initiating dialysis and continuing aggressive care in seriously ill hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Ann Intern Med 1997; 127:195–202.

2. Galla JH. Clinical practice guideline on shared decision-making in the appropriate initiation of and withdrawal from dialysis. The Renal Physicians Association and the American Society of Nephrology. J Am Soc Nephrol 2000; 11:1340–1342.

4. Bellomo R, et al. Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: The Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004; 8:R204–R212.

5. Maccariello ER, et al. Performance of six prognostic scores in critically ill patients receiving renal replacement therapy. Rev Bras Ter Intensiva 2008; 20:115–123.