In the JournalsPerspective

Older patients with kidney failure often see dialysis as the only option

A published study found older patients with advanced chronic kidney disease or ESKD, as well as their family members, lacked knowledge regarding alternatives to dialysis. According to the study authors, this lack of knowledge may limit the patient’s ability to make informed decisions about personal care.

“Although increasing numbers of adults 65 years and older are initiating kidney replacement therapy, there is a growing body of literature suggesting that a subset of patients, particularly those older than 75 years who have serious illnesses such as dementia or ischemic heart disease in addition to advanced chronic kidney disease, may not live longer with dialysis and may have worse quality of life and functional status after initiating dialysis,” Jennifer Karlin, MD, PhD, of the University of California, San Francisco, and colleagues wrote.

Interviewing patients (mean age, 72.4 years) and family members, researchers sought to explore the understanding of — and attitudes toward — kidney failure treatment options other than dialysis. The alternative focused on was conservative management, defined here as “a planned holistic approach incorporating symptom management, treatment to delay disease progression, advanced care planning and spiritual/psychological support for patients and their families.”

Interview responses revealed three primary themes. The first theme identified was patients and family members not viewing conservative management as a “viable personal option,” due to the option never being presented to them by their medical team or because it was presented in a way they did not understand. The second theme identified was that many patients and their families understood dialysis only in the abstract. To these participants, dialysis was “a hope for longer life,” with some misinterpreting the benefits of dialysis and believing that the kidneys would improve after initiation.

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Older patients with advanced chronic kidney disease or ESKD, as well as their family members, lacked knowledge regarding alternatives to dialysis.
Source: Adobe Stock

Finally, researchers found most patients and family members did not think there was a choice regarding treatment options. For these patients, not choosing dialysis meant death (even if conservative management would allow the patient to live just as long).

“Our study demonstrated that older patients with advanced CKD, including several currently receiving dialysis, and their family members have little or no understanding of conservative management and do not consider it a viable personal option,” the researchers wrote. “Conservative management programs need to become an established aspect of kidney failure care for patients who may not attain improved quality of life or longevity with dialysis. Providers involved in their care — nephrologists, primary care physicians, and ancillary staff — need to embrace conservative management as a realistic option for the treatment of kidney failure and learn how to communicate it effectively. Only then can we be sure that patients and their families are making truly informed decisions.” by Melissa J. Webb

Disclosures: The authors report no relevant financial disclosures.

A published study found older patients with advanced chronic kidney disease or ESKD, as well as their family members, lacked knowledge regarding alternatives to dialysis. According to the study authors, this lack of knowledge may limit the patient’s ability to make informed decisions about personal care.

“Although increasing numbers of adults 65 years and older are initiating kidney replacement therapy, there is a growing body of literature suggesting that a subset of patients, particularly those older than 75 years who have serious illnesses such as dementia or ischemic heart disease in addition to advanced chronic kidney disease, may not live longer with dialysis and may have worse quality of life and functional status after initiating dialysis,” Jennifer Karlin, MD, PhD, of the University of California, San Francisco, and colleagues wrote.

Interviewing patients (mean age, 72.4 years) and family members, researchers sought to explore the understanding of — and attitudes toward — kidney failure treatment options other than dialysis. The alternative focused on was conservative management, defined here as “a planned holistic approach incorporating symptom management, treatment to delay disease progression, advanced care planning and spiritual/psychological support for patients and their families.”

Interview responses revealed three primary themes. The first theme identified was patients and family members not viewing conservative management as a “viable personal option,” due to the option never being presented to them by their medical team or because it was presented in a way they did not understand. The second theme identified was that many patients and their families understood dialysis only in the abstract. To these participants, dialysis was “a hope for longer life,” with some misinterpreting the benefits of dialysis and believing that the kidneys would improve after initiation.

#
Older patients with advanced chronic kidney disease or ESKD, as well as their family members, lacked knowledge regarding alternatives to dialysis.
Source: Adobe Stock

Finally, researchers found most patients and family members did not think there was a choice regarding treatment options. For these patients, not choosing dialysis meant death (even if conservative management would allow the patient to live just as long).

“Our study demonstrated that older patients with advanced CKD, including several currently receiving dialysis, and their family members have little or no understanding of conservative management and do not consider it a viable personal option,” the researchers wrote. “Conservative management programs need to become an established aspect of kidney failure care for patients who may not attain improved quality of life or longevity with dialysis. Providers involved in their care — nephrologists, primary care physicians, and ancillary staff — need to embrace conservative management as a realistic option for the treatment of kidney failure and learn how to communicate it effectively. Only then can we be sure that patients and their families are making truly informed decisions.” by Melissa J. Webb

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Kathy Aebel-Groesch

    Kathy Aebel-Groesch

    Karlin and colleagues report in this study that older patients with advanced chronic kidney disease or ESKD, as well as their family members, lacked knowledge regarding alternatives to dialysis. The authors proposed this lack of knowledge may limit the patient’s ability to make informed decisions about personal care.

    “Although increasing numbers of adults 65 years and older are initiating kidney replacement therapy, there is a growing body of literature suggesting that a subset of patients, particularly those older than 75 years who have serious illnesses such as dementia or ischemic heart disease in addition to advanced chronic kidney disease, may not live longer with dialysis and may have worse quality of life and functional status after initiating dialysis,” they wrote.

    The researchers interviewed patients whose mean age was 72.4 years and their family members. They summarized three themes — patients did not consider conservative treatment to be a “viable” option, they did not understand the potential impact of dialysis treatment options on their lives and they did not perceive they even had a choice — “for these patients, not choosing dialysis meant death (even if conservative management would allow the patient to live just as long).”

    As clinicians, we have an obligation to help patients make informed decisions about their care, particularly when approaching end of life. Providing comprehensive education about treatment options for ESKD — transplant, home dialysis (PD and HHD), in-center dialysis and conservative/supportive care — to both patients and their care partners—is crucial.

    Considering their health literacy and cognitive status, patients may be more likely to comprehend their options when the information is presented in a variety of ways. Many CKD educational programs, such as those offered by large dialysis organizations and the National Kidney Foundation, use multimedia approaches to present treatment options, including conservative/supportive care. Renal professionals should collaborate with trusted primary care providers to ensure palliative care is presented as a viable treatment option, especially when the burden of dialysis outweighs the potential benefit.

    As Atul Gawande wrote in Being mortal, “We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. … Whenever serious sickness or injury strikes … the vital questions are the same:  What is your understanding of the situation and its potential outcomes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?”

    Reference:

    Gawande, A. Being mortal: Medicine and what matters in the end. Metropolitan Books. 2014.

    • Kathy Aebel-Groesch, MSW, LCSW
    • Manager, Social Work Services
      DaVita Kidney Care
      St. Louis
      Nephrology News & Issues Editorial Board Member

    Disclosures: Aebel-Groesch reports no relevant financial disclosures.