PRESENTED BY
MONIKA LICHODZIEJEWSKA-NIEMIERKO

Presentation Summary

Writen by Jasna Trbojevic-Stankovic
Reviewed by Monika Lichodziejewska-Niemierko

Not more than sixty years ago renal patients were selected to receive dialytic treatments based on rather strict rules. Nowadays, situation has changed drastically. The increase in life expectancy and technological advances, which provided modern medicine with availability of various treatments to keep the patient alive, have prompted situations in which prolonged survival may not be accompanied by an acceptable quality of life. The versatility of contemporary renal replacement therapies can literally provide a solution for any renal failure scenario, even in cases with high comorbidity rates and very limited short-term survival expectations. Still, discontinuation of dialysis is always a challenging decision to make for either nephrologists, patients or caretakers.

One of the most useful questions to ask when reviewing a patient as suggested by Brown et al. would be: Would I be surprised if the patient was to die in the next 12 months? [1]. Besides this one, a number of other general, cardiovascular or distinct comorbid conditions, as well as some dialysis-related factors, have been proposed as clinical features of end of life [1].

The interest in this subject has increased in the recent years and several papers have examined and identified the potential triggers to identify the patients for whom withdrawal should be considered [2, 3]. Some emphasize the patient-centered instead of the common disease-centered approach to end-of life care designating accelerating comorbid illness, increased frequency of hospitalization, failure to thrive, presence of nonrenal terminal illness, poor prognosis, loss of function and loss of personal drive to continue, with physician answer “no” to the “surprise” question as possible triggers that may prompt the patient to inquire about the possibility to discontinue dialysis treatment [2]. Others report association between female sex, increasing age, prior cerebrovascular disease, chronic obstructive pulmonary disease, sepsis and higher disability score as significantly influential variables for dialysis withdrawal [3, 4]. Interestingly, there seems to be culture or social factors, as not yet fully defined, associated with withdrawal since Blacks, Asians, and Hispanics are less likely to withdraw than whites [4]. Furthermore, the phenomenon that calls for more investigation is the notably higher rate of dialysis withdrawal in North America than in Europe [5].

Another important point related to this subject which has not been well established is the association between end-stage renal disease (ESRD) and dialysis with suicide [6]. There seems to be a significant association between ESRD and suicide warranting assessment of mental physical disorders in these patients, particularly at the onset of dialysis treatment [6].

Besides the scarcity of research on dialysis withdrawal and associated factors, the problem is also the inconsistency in definitions, thus yielding disparity in study findings. The definition of dialysis withdrawal varies across researches from dialysis discontinuation, to withholding, withdrawal, treatment refusal/cessation or technique failure [5]. A recently introduced Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life in South Korea has prompted introduction of meticulous terminology related to life-sustaining treatments at patients’ end of life which can be used in future studies on dialysis withdrawal [7].

An honest and opened conversation should provide the physician with a better insight into patients’ perception of what is important to him/her and provide a platform for shared decision making [8]. Studies show that patients’ priorities may differ from nephrologists’, and may even vary in different patient groups, particularly related to their age [9, 10]. Several ways to improve advance care planning for CKD and ESRD patients have been suggested, including involvement of an interdisciplinary team, timely reviewing care goals with patients and their families and considering whether to initiate dialysis through weighing both pros and cons in the context of patients’ comorbidities and personal values [11]. The latter strategies rely on serious illness conversations which involve addressing the patients’ experience of their illness and quality of life and sharing of goals, fears and concerns [12]. Such conversations, however, occur infrequently and, as a rule, nephrologists are not trained to lead them. The adequate, interpretive, approach requires significant time, training and comfort to discuss difficult topics and establish a trusting doctor-patient relationship when discussing such serious matters [13]. Patients often report feeling alienated, isolated and abandoned when it comes to serious discussions related to the choice of their future care [14]. Not less important is the need to build a trusting relationship with patients’ families and involve them in deciding about future health care as well. A recent study has shown that treatment-limiting directives and surrogates were associated with fewer intensive interventions and inpatient deaths among nursing home residents receiving dialysis [15].

Fortunately, the nephrologists’ perception is changing and more and more physicians acknowledge the need to introduce the module of palliative care in the nephrology training curriculum [16]. Such training would provide the necessary knowledge on alleviating the symptoms and managing the medical, psychosocial and spiritual aspects of end-of-life care for the patients who decide to withdraw from dialysis and opt for continued palliative care [17, 18]. What nephrologists should never forget is that “the aim of dialysis is not only to prolong life, but also to restore quality by permitting a sufficiently independent existence with minimal support” [19].

References

1. Brown EA, Chambers EJ, Eggeling C. . Palliative care in nephrology. . Nephrol Dial Transplant. 2008;23(3):789-91. DOI: 10.1093/ndt/gfm874

2. Schmidt RJ, Moss AH. . Dying on dialysis: the case for a dignified withdrawal. . Clin J Am Soc Nephrol. 2014;9(1):174-80. DOI: 10.2215/CJN.05730513

3. Findlay MD, Donaldson K, Doyle A et al.. Factors influencing withdrawal from dialysis: a national registry study. . Nephrol Dial Transplant. 2016;31(12):2041-2048. DOI: 10.1093/ndt/gfw074

4. Wetmore JB, Yan H, Hu Y, Gilbertson DT, Liu J. . Factors Associated With Withdrawal From Maintenance Dialysis: A Case-Control Analysis. . Am J Kidney Dis. 2018;71(6):831-841.. DOI: 10.1053/j.ajkd.2017.10.025

5. Qazi HA, Chen H, Zhu M. . Factors influencing dialysis withdrawal: a scoping review.. BMC Nephrol. 2018;19(1):96.. DOI: 10.1186/s12882-018-0894-5

6. Liu CH, Yeh MK, Weng SC, Bai MY, Chang JC. Suicide and chronic kidney disease: a case-control study.. Nephrol Dial Transplant. 2017;32(9):1524-1529. DOI: 10.1093/ndt/gfw244

7. Shin SJ, Lee JH.. Hemodialysis as a life-sustaining treatment at the end of life. . Kidney Res Clin Pract. 2018;37(2):112-118. DOI: 10.23876/j.krcp.2018.37.2.112

8. Muthalagappan S, Johansson L, Kong WM, Brown EA. . Dialysis or conservative care for frail older patients: ethics of shared decision-making. . Nephrol Dial Transplant. 2013;28(11):2717-22. DOI: 10.1093/ndt/gft245

9. Manera KE, Johnson DW, Craig JC et al. . Patient and Caregiver Priorities for Outcomes in Peritoneal Dialysis: Multinational Nominal Group Technique Study. . Clin J Am Soc Nephrol. 2019;14(1):74-83. DOI: 10.2215/CJN.05380518

10. Selman LE, Bristowe K, Higginson IJ, Murtagh FEM. . The views and experiences of older people with conservatively managed renal failure: a qualitative study of communication, information and decision-making. . BMC Nephrol. 2019;20(1):38.. DOI: 10.1186/s12882-019-1230-4

11. Rak A, Raina R, Suh TT et al. . Palliative care for patients with end-stage renal disease: approach to treatment that aims to improve quality of life and relieve suffering for patients (and families) with chronic illnesses. . Clin Kidney J. 2017;10(1):68-73. DOI: 10.1093/ckj/sfw105

12. Mandel EI, Bernacki RE, Block SD.. Serious Illness Conversations in ESRD. . Clin J Am Soc Nephrol. 2017;12(5):854-863. DOI: 10.2215/CJN.05760516

13. Ladin K, Pandya R, Perrone RD et al. . Characterizing Approaches to Dialysis Decision Making with Older Adults: A Qualitative Study of Nephrologists. . Clin J Am Soc Nephrol. 2018;13(8):1188-1196. DOI: 10.2215/CJN.01740218

14. O’Hare AM, Richards C, Szarka J et al. . Emotional Impact of Illness and Care on Patients with Advanced Kidney Disease. . Clin J Am Soc Nephrol. 2018;13(7):1022-1029. DOI: 10.2215/CJN.14261217

15. Kurella Tamura M, Montez-Rath ME, Hall YN, Katz R, O’Hare AM. . Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis. . Clin J Am Soc Nephrol. 2017;12(3):435-442.. DOI: 10.2215/CJN.07510716

16. Lichodziejewska-Niemierko M, Rutkowski B.. Palliative care in nephrology. . J Nephrol. 2008;21 Suppl 13:S153-7.. DOI: /

17. Germain MJ, Cohen LM, Davison SN. . Withholding and withdrawal from dialysis: what we know about how our patients die.. Semin Dial. 2007;20(3):195-9. DOI: /

18. Chater S, Davison SN, Germain MJ, Cohen LM. . Withdrawal from dialysis: a palliative care perspective. . Clin Nephrol. 2006;66(5):364-72. DOI: 1. 10.5414/cnp66364

19. Holley JL. . Advance care planning in CKD/ESRD: an evolving process. Clin J Am Soc Nephrol. 2012;7(6):1033-8. DOI: 10.2215/CJN.00580112

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