Dialysis discontinuation: quo vadis?

Approximately 1 in 4 deaths of patients maintained on dialysis in the United States is preceded by a decision to discontinue treatment. Once considered to be a form of suicide, dialysis discontinuation is now increasingly common in most countries that are fortunate enough to offer renal replacement therapies. Given an aging and progressively sicker chronic kidney disease patient population, the rate of terminating dialysis is likely to increase. The literature on dialysis discontinuation includes studies principally from Canada, the United Kingdom, and the United States. The research is reviewed, critiqued, and examined to determine its relevance to practice. Future issues include the need to explore variability in dialysis practice as well as employment of a more patient-centered approach that is consistent with modern palliative medicine.

Advance Care Planning by or on Behalf of Peritoneal Dialysis Patients in Long-Term Care

BACKGROUND

Advance care planning (ACP) is recommended for dialysis patients, especially those living in long-term-care facilities. Factors influencing ACP and the effect of plans on outcome are incompletely studied.

METHODS

We performed a retrospective chart review and follow-up of all peritoneal dialysis patients admitted to an academic nursing home between 1986 and 2000 and abstracted demographics, comorbidities, functional status as activities of daily living (ADL) score, documentation of ACP, and actual interventions.

RESULTS

Of 109 patients, 108 had ACP; of these, patients participated in 71%. Plans to do not attempt resuscitation (DNAR) were associated with the presence of coronary disease (odds ratio, 4.24; confidence interval [CI], 1.49 to 12.02), lower ADL score (odds ratio, 1.22; CI, 1.08 to 1.38), and older age (odds ratio, 1.04; CI, 1.0007 to 1.09). Plans to do not hospitalize (DNH) were associated with ADL score only (odds ratio, 1.26; CI, 1.07 to 1.48). Patients with DNAR plans had poorer 3-, 6-, and 12-month survival (P < 0.02), but not after adjustment for age of 75 years or older, poor functional status, coronary disease, and decubiti. Plan compliance was limited. DNH plans were not associated with the likelihood of hospitalization (5 of 14 versus 42 of 93 patients) or length of stay (11.0 +/- 16.4 versus 8.0 +/- 15.1 days). Compliance with DNAR plans was determined for 81 of 108 patients. No patient with a DNAR plan had resuscitation attempted. Only 7 of 46 patients with plans to undergo resuscitation had it attempted.

CONCLUSION

For these chronically ill patients, age and functional status strongly influence DNAR and DNH plans. ACP was not decisive in determining events during acute illness.

The role of depression symptoms in dialysis withdrawal

Among end-stage renal disease (ESRD) patients on hemodialysis, death from withdrawal from life-sustaining dialysis is increasingly common. The present study's objective was to examine depression as a potential risk factor for hemodialysis withdrawal. Two hundred forty ESRD hemodialysis (133 male and 107 female) patients were followed for an average of 4 years after depression symptom assessment. Of these, 18% withdrew from dialysis. Using multivariate survival analysis and after controlling for the effects of age (p < .001) and clinical variables, the authors found that level of depression symptoms was a unique and significant predictive risk factor for the subsequent decision to withdraw from dialysis (p < .05). The potential impact that depression may have on the decision to withdraw from hemodialysis should be considered by health care providers, patient families, and patients.

Interventions to Improve Care during Withdrawal of Life-Sustaining Treatments

Withdrawal of life-sustaining therapies is a common occurrence in the intensive care unit (ICU) setting and also occurs in other hospital settings, long-term care facilities, and even at home. Many studies have documented dramatic geographic variations in the prevalence of withdrawal of life-sustaining therapies, and some evidence suggests this variation may be driven more by physician attitudes and biases than by factors such as patient preferences or cultural differences. A number of studies of interventions in the ICU setting have provided some evidence that withdrawal of life-sustaining therapies is a process of care that can be improved. The interventions have included routine ethics or palliative care consultations, routine family conferences, and standardized order protocol for withdrawal of life support. For some of the interventions, for example, ethics consultations or palliative care consultations, the precise mechanisms by which the process of care is improved are not clear. Furthermore, many of these studies have used surrogate outcomes for quality, such as ICU length of stay. Emerging research suggests more direct outcome measures may be useful, including family satisfaction with care and assessments of the quality of dying. Despite these relative limitations, these studies provide convincing evidence that withdrawal of life-sustaining therapy is a process of care that presents opportunities for quality improvement and that interventions are successful at improving this care. Further research is needed to identify and test the most appropriate and responsive outcome measures and to identify the most effective and cost-effective interventions.

Quality end-of-life care in dialysis units

Quality end-of-life care has not been a priority in dialysis units and patients often experience prolonged dying while suffering needlessly. Advance directives (ADs) and decisions to stop dialysis have been highlighted by the medical profession as priorities in improving the quality of care, yet these are only two aspects of end-of-life care. They may not reflect patients' priorities and may not have the expected impact in improving the quality of end-of-life care. This review argues that quality end-of-life care should be a clinical priority in the care of dialysis patients; end-of-life care needs to be developed primarily from the patients' perspective; a clinical framework is required that integrates many aspects of end-of-life care; and end-of-life care should be initiated much earlier in the course of patients' illnesses than traditionally is done. By communicating more effectively and sooner with patients, their values and needs can be identified so we will be better able to plan and facilitate their end-of-life care and improve their experience of dying.

Evaluating an activity intervention with hemodialysis patients in Israel

As a life-threatening and potentially disabling disease, End Stage Renal Disease and its treatment cause stress as well as other psychosocial problems for patients and their families. This paper examines the results of an innovative activity-based intervention aimed at reducing some of the psychosocial repercussions of hemodialysis. A modified withdrawal/reversal design was employed to compare patients participating in the intervention and those who did not, at two points in time. The findings confirmed that dialysis patients in general have relatively high levels of psychological distress, difficulty adhering to the treatment regimen and poor self-rated health. Patients participating in the group activity were more anxious and had lower levels of interdialytic weight gain than the non-participants. After the intervention was terminated, levels of psychological distress, hostility and phobic anxiety among patients in the treatment group dropped, while their weight gain continued to be less than that of non-participating patients. The implications of these findings as well as the methodological difficulties entailed in this type of study are examined.