COMMENTARY Dialysis: Is it for the very elderly?

For many years it has been evident that the dialysis population in the US has a higher mortality than similar high-income countries in Europe or to our north in Canada. The generally accepted reason is that the US dialysis population is older and sicker.  Delicia Honen Yard in the September 9 issue of Renal and Urology News interviews, among others, one of the most respected clinical nephrologists in the United States, Dr. Eli Friedman, from Downstate in Brooklyn, New York.  Dr. Friedman is quoted as saying: “There is a difference in reported survival of treated patients with kidney failure in the United States as compared with Europe or other industrialized nations…The difference could be that we treat patients who shouldn't be treated, and they have poor prognosis and they die.”

This leads me to discuss a thoughtful article in Health Affairs by Dr. Katherine Chang Chretien titled “Driven To Dialysis? A Very Sick Nonagenarian Develops Kidney Failure”. In this article, Dr. Chertien argues that one of the unique aspects of the dialysis population in the US is that we have a relatively larger number of elderly patients – in their eighties and nineties.

Dr. Friedman: “If you look at Canada, there's no rule that says, ‘Don't dialyze patients who are over the age of 75.' But if you try to find patients over the age of 75 in Canada who are on dialysis, they're almost nonexistent. That's because they're not referred from the general practitioner to the nephrologist. The argument is that the apparent difference in selection therapy represents the ability of the country to support the population who would benefit from therapy.”

Dr. Chertien writes in her article: “The number of octogenarians and nonagenarians starting dialysis in the United States is growing: The number has increased an estimated 57 percent from 1996 (7,054 patients) to 2003 (13,577 patients), according to a 2007 study in the Annals of Internal Medicine. Yet their death rate, after one year, is nearly 50 percent. For those over age ninety who start dialysis, the average length of survival is 8.4 months, compared to those starting dialysis at ages 65–79, who live an average of 24.9 months…..Ever since the Medicare End-Stage Renal Disease Program was passed by Congress in 1973, dialysis has been accessible to almost anyone in the United States who needs it, regardless of medical prognosis or whether the person already has a terminal illness”. Dr. Chertien continues:

Rethinking How And Why

Going forward, as we increasingly face the branch on the decision tree of dialysis or not dialysis, doctors and policy makers need to assess whether we’re adequately preparing patients and families to make fully informed decisions. Enabling families to do so is much more difficult than it sounds. Communicating different options in a way that is easily understood isn’t a skill usually taught in medical school; besides, our biases can influence the way we present information. And even when patients and their families have all the known risks, benefits, and alternatives clearly laid out for them, they still might not understand everything in a situation that requires complex decision making.

A more standardized approach for doctors to follow in these kinds of situations could help better guide patients and keep them at the center of medical decisions involving their care. Although this wouldn’t address all of the barriers to communicating risks and benefits in complex medical decisions, it would be a start.
A standardized approach to a medical decision concerning dialysis, for instance, might follow a set of counseling guidelines. Holding a “shared decision making” meeting involving the patient’s whole family along with the full physician care team could serve to clarify the patient’s values and goals. It could be the time to establish a treatment plan that everyone in the room accepted and understood. Well ahead of this, the doctors involved should have in-depth education about the true risks and benefits of dialysis, how to communicate them, and the goals and philosophy of hospice care.

Since Medicare beneficiaries are entitled to receive dialysis if they need it, is it possible for doctors, administrators, or policy makers to restrict the access of elderly patient’s -- with or without comorbidities -- to dialysis treatment? Not in the US, in my view. The best approach is the one recommended by Dr. Chertien, which emphasizes the themes of "in-depth education about the true risks and benefits of dialysis.. and holding a “shared decision making” meeting involving the patient’s whole family along with the full physician care team...to clarify the patient’s values and goals".