Elderly on dialysis: conservative care

Question 1

From a patient perspective what do they want from dialysis

Answer 1

Relieve symptoms

Quality of life goals
(Social and family interactions
Physical activity: travel, work, exercise, self-care
Mental activity: work, hobbies)

Extend life

Avoid complications of treatment

Question 2

What does the doctor want from dialysis

Answer 2

Sick patient – have to do something
Meets criteria for starting dialysis
Belief that dialysis will benefit patient
Patient may not do well, but lets give dialysis a try
easier than long conversation about prognosis, end of life wishes, etc

Question 3

What factors to consider if old and on dialysis

Answer 3

Multiple comorbidities
Physical function
Cognitive function
Nutritional status
Depression
Social isolation
Vision
Hearing
Social support

Question 4

Risk score for how long people will survive on dialysis

Answer 4

Body mass index <18.5 kg/m2 (1 point)
Congestive heart failure stages III-IV (2 points)
Peripheral vascular disease stages III-IV (2 points)
Dysrhythmia (1 point)
Active malignancy (1 point)
Severe behavioural disorder (2 points)
Total dependency for transfers (3 points)
Unplanned dialysis (2 points)

Question 5

Is there survival benefit for those over 75 having dialysis

Answer 5

Not in some studies

Question 6

Patient autonomy as an ethical principle in dialysis

Answer 6

Patients must be given realistic and accurate information to enable them to make appropriate decision
Patients cannot demand treatment if not appropriate
Not relevant if patient lacks capacity

Question 7

Beneficence as an ethical principle in dialysis

Answer 7

i.e. dialysis should benefit patient
Prolongs survival
Improves quality of life
Improves symptom burden

Question 8

Avoidance of harm as an ethical principle in dialysis

Answer 8

i.e. dialysis should not harm patient
Shortens survival
No improvement or worse quality of life
Increases symptom burden

Question 9

Justice as an ethical principle in dialysis

Answer 9

Limited resources in all healthcare systems
Dialysing patients who would not benefit leads to
Dialysis staff/machines not being available for patient who may benefit
Money/resources not being available for other healthcare needs

Question 10

What is conservative care in renal failure

Answer 10

Non-dialysis pathway chosen by patient after shared decision making with predialysis team
Active management of anaemia with ESA and intravenous iron
BP control – slow rate of decline and lower stroke risk
Optimise fluid balance – avoid over and under hydration
Symptom control, including pain
Joint management with palliative care team at end of life phase