This thoughtful article about dialysis for older people with kidney disease captures the dilemma that many elderly patients must go through: whether they wish to endure the often difficult, inconvenient, and unpleasant task of frequent trips to a renal center for dialysis or to live out their days having the end of their lives managed without it. Since the cohort being discussed here — people over 75 with kidney failure and other chronic diseases — face imminent death (nearly 60 percent die within a year of starting dialysis), it is heartening that these vital questions about the medical intensiveness of the last year or so of a life are being asked. The article includes useful quantification of the disease in question, the concerns of patients, and the fact that the needs of patients might not be solicited.
This piece describes the reality of a common, costly, and time-intensive medical intervention, then identifies a major flaw in its execution: many patients don’t understand what they’re getting into, and wouldn’t proceed if they did. The emphasis on shared decision-making is key.
The article could have included some quick facts about the cost of dialysis, as well as the costs of transportation, hospital time and nursing costs that are all involved in being treated as an out-patient at a renal clinic. There was one reference to costs when the story says that, in terms of time, dialysis treatment was “the equivalent of holding down a part-time job.”
The article cited appropriate studies for a range of statistics. We learn, for example, that “58% of patients died within a year of beginning dialysis” and that about 40% of patients over 75 with end-stage renal disease die within a year. We also learn about the concerns of the patients, including the fact that 61% of patients in one study said they regretted starting dialysis. It adds that “withdrawal from treatment accounted for about a quarter of deaths of dialysis patients in 2006,” though that seems a little unsatisfying in terms of what additional lifespan might be attributed to dialysis. Another fact included is that 66% of patients in one study told researchers that their doctors had not mentioned the treatment’s risks or burdens, and they felt they had no choice.
Harms are explained in terms of the side effects of the dialysis, the pain, nausea and feeling “dizzy, washed out.” It was good that the article explained that the harms of dialysis are also measured in other ways: the disruption to a person’s life, the need to travel and go in and out of facilities, and the effects on their independence, which can be debilitating for older people.
Numerous studies, surveys and statistical analyses are cited in the article, which adequately back up the main points that it is making.
If anything, this article is protective against disease-mongering. It questions the idea that everyone with a particular disease should get treatment, regardless of other factors.
There are numerous sources both quoted and cited in the story, so we are giving it a pass here. At the same time, we would have liked to have heard the evidence-based opinion of a strong advocate for end-of-life dialysis. The counterpoint in this case might have been a doctor saying that patients have a hard time sharing in decisions or sometimes do not want to do so.
The article mentions peritoneal dialysis, which can be done at home, but fewer than 10 percent of patients opt for that. It would have been useful to know why home-based dialysis is so underused.
The story presents it as a given that dialysis, renal clinics and so on are common in the health system.
What might be considered “novel” is the fact of saying “no” to dialysis. What we don’t learn is if “saying no” to dialysis is that novel of a concept. How do other countries treat the question? Are rates of dialysis in the US that much different than other countries? An international comparison would have been welcome here.
This article does not in any way appear to rely on a news release.
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Comments (1)
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Paula Span
April 2, 2015 at 11:32 amI’m pleased that the reviewers found my New Old Age column mostly satisfactory. Let me clarify that one of the statistics you cite — 58 percent mortality within a year of initiating dialysis — refers to nursing home residents, a population that almost by definition is frailer and less healthy than older adults living in the community. The finding comes from this 2009 study by Tamura, Covinsky et. al. in NEJM: http://www.nejm.org/doi/full/10.1056/NEJMoa0904655
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