A recent article in The New England Journal of Medicine emphasizes the ethical importance of giving well-educated patients true choices when it comes to management of advanced chronic kidney disease, especially regarding potential dialysis cessation (1). Through coordination with palliative care specialists, nephrologists can offer patients a wide variety of options to help meet their specific personal needs and goals.
Although a vital, life-saving therapy, dialysis can come with side effects and significant psychological, social, and financial pressures on patients. Solomon Liao, MD, is director of palliative care at the University of California, Irvine, and one of the paper’s coauthors. He points out that dialysis, especially as pursued in traditional models, may not be the right choice for some elderly and frail patients with multiple medical morbidities, who may not live much longer even with dialysis.
Yet the choice to end dialysis—or to not initiate it in the first place—must be made thoughtfully, by exploring the variety of available options in a non-pressured way, as death may come fairly quickly after dialysis cessation of hospitalized patients.
Kamyar Kalantar-Zadeh, MD, MPH, PhD, a co-author of the paper, noted that one of the worst times to begin this conversation is when patients with kidney failure are hospitalized and critically ill. Kalantar-Zadeh is a professor of medicine and chief of the nephrology division at the University of California, Irvine.
Financial incentives could impede clear decision-making
Because of changes made through the Affordable Care Act, hospitals have financial incentives to reduce the length of hospital stays and prevent hospital readmissions within 30 days of a previous hospitalization. This is especially pertinent to people with kidney failure, who often have multiple significant medical morbidities.
The authors expressed concern that these and other factors might lead to undue pressure to get some people with kidney failure off dialysis. The COVID-19 pandemic heightens these concerns, as nephrologists may feel pushed to get their dialysis patients out of needed ICU beds via abrupt dialysis withdrawal and hospice initiation.
“I worry that dialysis patients will become a lower priority,” Kalantar-Zadeh said. “We need to make sure that some of these perverse incentives and other important goals do not cause a conflict of interest to compromise patient choice. Patients should not feel forced to stop dialysis, in the same way that patients shouldn’t feel pressured to start dialysis.”
Kalantar-Zadeh and colleagues noted that when it is discussed, the decision to continue dialysis is often presented in stark opposition to comfort treatments. Yet many integrated options exist that may better meet many patients’ needs. For some patients, conservative therapy such as dietary and lifestyle interventions, pharmacotherapy, and active symptom management can help preserve the kidneys and delay the need for dialysis.
Gradual transition to dialysis is another option, perhaps starting at less than standard dialysis frequencies. An expanded palliative care role could be an option for some patients, with patients managed by palliative care professionals both during hospitalization and as outpatients. Dialysis frequency and intensity can also be decreased gradually with a primary aim of reducing symptoms in conjunction with hospice care.
But patients often do not have an idea of the spectrum of options available to them, thinking that standard dialysis is the only choice other than total care cessation. Even other health professionals may lack the understanding of options held by nephrologists, one of the reasons it is critical that nephrologists be included in any discussion of dialysis cessation or transition plans to less aggressive intervention.
Some nephrologists might not begin the discussion early enough, when there is still time for patients and their family members to ask questions, digest the information, and consider their personal goals.
“Physicians fear that if they bring up these issues patients will get mad at them or pull away,” said Liao. “But the medical literature shows that patients and families actually appreciate it when doctors bring up these issues.” He emphasized the need to have such conversations early in treatment, ideally at dialysis initiation, to be revisited as needs and goals change.
With COVID-19, it is even more important for patients with kidney failure to have plans about how they would like to be managed in the hospital if they do become sick. Such conversations, Liao noted, can reduce patient anxieties in a turbulent time.
Nephrologists should not hesitate to work in collaboration with palliative doctors, who are expertly positioned to help with symptom management and integrative care approaches. Liao emphasized that every home hemodialysis patient should have a palliative medicine team following their care as well.
Various administrative issues and structural barriers can make collaboration between nephrologists and palliative care professionals challenging, such as credentialing and reimbursement issues at joint clinics. However, academic centers can facilitate exchanges to educate nephrologists about relevant palliative care perspectives and vice versa.
The main goal remains a shared one: making sure patients are given choices, truly informed choices, that uphold their overall health, dignity, and personal hopes.
Reference
Kalantar-Zadeh K, et al. Ensuring choice for people with kidney failure—dialysis, supportive care, and hope. N Engl J Med 2020; 383:99. doi:10.1056/NEJMp2001794
