Race- and Ethnicity-Related Disparities in Predialysis Nephrology Care, Kidney Disease Education, and Home Dialysis Utilization

Key Points

Disparities in predialysis nephrology care and KRT-directed education significantly influenced home dialysis underuse among marginalized populations. The influence of predialysis care disparities on home dialysis underuse lasted for a long time even after starting the dialysis. More studies are needed to uncover the layers through which structural racism influences home dialysis underuse among marginalized populations.

Background

Predialysis nephrology care and KRT-directed education (KDE) are essential for incident home dialysis use. However, there are substantial disparities in these care parameters among patients with advanced CKD. The effect of these disparities on home dialysis underuse has not been examined.

Methods

We analyzed the 2021 United States Renal Database System to identify all adult patients with kidney failure with over 6 months of predialysis Medicare coverage initiating their first-ever dialysis between 2010 and 2019. We used a mediation analysis to dissect the attributable influence of disparities in predialysis nephrology care and KDE on incident home dialysis use. In addition, we conducted sensitivity analyses using graded levels of mediators and sustained effect on home dialysis outcomes.

Results

We identified 464,310 Medicare recipients: 428,301 using in-center hemodialysis and 35,416 using home dialysis as their first-ever dialysis modality during the study period. Compared with non-Hispanic White patients (n =294,914), adjusted odds ratio (95% confidence intervals) for receiving predialysis nephrology care, KDE service, and incident home dialysis were 0.62 (0.61 to 0.64), 0.58 (0.52 to 0.63), and 0.76 (0.73 to 0.79), respectively, among Hispanic individuals (n =49,734) and 0.74 (0.73 to 0.76), 0.84 (0.79 to 0.89), and 0.63 (0.61 to 0.65), respectively, among Black individuals (n =98,992). Mediation analyses showed that compared with non-Hispanic White individuals, lack of nephrology care explained 30% and 14% of incident home dialysis underuse among Hispanic and Black individuals, respectively (P < 0.001). Sensitivity analyses using a longer duration of nephrology care and KDE services and the sustained effect on home dialysis underuse through the first year after kidney failure showed congruent and consolidating findings.

Conclusions

Disparities in predialysis nephrology care were significantly associated with lower home dialysis use among Hispanic and Black individuals.

Decision-Making Engagement Preferences among Older Adults with CKD

Key Points

Clinicians’ uncertainty about the degree to which older patients prefer to engage in decision making remains a key barrier to shared decision making. Most older adults with advanced CKD preferred a collaborative or active role in decision making.

Background

Older adults with kidney failure face preference-sensitive decisions regarding dialysis initiation. Despite recommendations, few older patients with kidney failure experience shared decision making. Clinician uncertainty about the degree to which older patients prefer to engage in decision making remains a key barrier.

Methods

This study follows a mixed-methods explanatory, longitudinal, sequential design at four diverse US centers with patients (English-fluent, aged ≥70 years, CKD stages 4–5, nondialysis) from 2018 to 2020. Patient preferences for engagement in decision making were assessed using the Control Preferences Scale, reflecting the degree to which patients want to be involved in their decision making: active (the patient prefers to make the final decision), collaborative (the patient wants to share decision making with the clinician), or passive (the patient wants the clinician to make the final decision) roles. Semistructured interviews about engagement and decision making were conducted in two waves (2019, 2020) with purposively sampled patients and clinicians. Descriptive statistics and ANOVA were used for quantitative analyses; thematic and narrative analyses were used for qualitative data.

Results

Among 363 patient participants, mean age was 78±6 years, 42% were female, and 21% had a high school education or less. Control Preferences Scale responses reflected that patients preferred to engage actively (48%) or collaboratively (43%) versus passively (8%). Preferred roles remained stable at 3-month follow-up. Seventy-six participants completed interviews (45 patients, 31 clinicians). Four themes emerged: control preference roles reflect levels of decisional engagement; clinicians control information flow, especially about prognosis; adapting a clinical approach to patient preferred roles; and clinicians' responsiveness to patient preferred roles supports patients' satisfaction with shared decision making.

Conclusions

Most older adults with advanced CKD preferred a collaborative or active role in decision making. Appropriately matched information flow with patient preferences was critical for satisfaction with shared decision making.

Clinical Trial registry name and registration number:

Decision Aid for Renal Therapy (DART), NCT03522740 .

Development and Acceptability of a Kidney Therapy Decision Aid for Patients Aged 75 Years and Older: A Design-Based Research Involving Patients, Caregivers, and a Multidisciplinary Team

Rationale & Objective

Many older adults prefer quality of life over longevity, and some prefer conservative kidney management (CKM) over dialysis. There is a lack of patient-decision aids for adults aged 75 years or older facing kidney therapy decisions, which not only include information on dialysis and CKM but also encourage end-of-life planning. We iteratively developed a paper-based patient-decision aid for older people with low literacy and conducted surveys to assess its acceptability.

Study Design

Design-based research.

Setting and Participants

Informed by design-based research principles and theory of behavioral activation, a multidisciplinary team of experts created a first version of the patient-decision aid containing 2 components: (1) educational material about kidney therapy options such as CKM, and (2) a question prompt list relevant to kidney therapy and end-of-life decision making. On the basis of the acceptability input of patients and caregivers, separate qualitative interviews of 35 people receiving maintenance dialysis, and with the independent feedback of educated layperson, we further modified the patient-decision aid to create a second version.

Analytical Approach

We used descriptive statistics to present the results of acceptability surveys and thematic content analyses for patients' qualitative interviews.

Results

The mean age of patients (n=21) who tested the patient-decision aid was 80 years and the mean age of caregivers (n=9) was 70 years. All respondents held positive views about the educational component and would recommend the educational component to others (100% patients and caregivers). Most of the patients reported that the question prompt list helped them put concerns into words (80% patients and 88% caregivers) and would recommend the question prompt list to others (95% patients and 100% caregivers).

Limitations

Single-center study.

Conclusions

Both components of the patient-decision aid received high acceptability ratings. We plan to launch a larger effectiveness study to test the outcomes of a decision-supporting intervention combining the patient-decision aid with palliative care-based decision coaching.

Haemodialysis patient's adherence to treatment: Relationships among nurse-patient-initiated participation and nurse's attitude towards patient participation

AIMS AND OBJECTIVES

To evaluate the relationship between nurse-patient-initiated participation, nurses' attitudes towards patient's participation, and patients' adherence to treatment. Specifically, to (1) explore nurse-patient participation during haemodialysis and quantify the information into measurable indices; (2) determine the haemodialysis patient's adherence to treatment; (3) describe nurses' attitudes towards patient participation; and (4) establish the relationships between nurse-patient-initiated participation, nurses' attitudes towards patient participation and patients' adherence to treatment.

BACKGROUND

To improve haemodialysis patients' health, it is crucial to identify nurses' and patients' factors facilitating adherence to treatment.

DESIGN

An exploratory-sequential mixed-methods (quantitative and qualitative) design.

METHODS

All nurses working at a dialysis ward (n = 30) and their randomly selected patients (n = 102) participated. Qualitative data on nurse-patient-initiated participation were derived from transcribed nurse-patient conversations and quantified for further analyses. Nurses' attitudes towards patient participation were collected via questionnaire, and adherence to treatment via observed reduction in prescribed haemodialysis time. [CONSORT-SPI guidelines].

RESULTS

Content analysis of the conversations indicated that nurse-initiated participation focused on patient's medical condition, treatment plan and education; while patients initiated more small talk. Non-adherence to treatment was significant (Mean = 0.19 h; SD = 0.33). Regression analyses indicated that nurses' attitude towards participation was negatively linked to patient adherence, while patient-nurse-initiated participation was unrelated. Nurses' attitudes towards patient participation moderated the relationship between nurse-patient-initiated participation and patient adherence: the more positive the attitude towards inclusion the more negative the link between patient or nurse-initiated participation and patient adherence.

CONCLUSIONS

The findings provided paradoxical insights: Nurses' positive attitudes towards participation lead them to accept the patient's position for shortening haemodialysis treatment, so that adherence to care decreases.

RELEVANCE TO CLINICAL PRACTICE

Nurses require education on negotiating methods to help achieve patient adherence while respecting the patient's opinion. Patients should be educated how to approach nurses, seeking the information they need.

Asking the right questions: towards a person-centered conception of shared decision-making regarding treatment of advanced chronic kidney disease in older patients

An increasing number of older patients have to decide on a treatment plan for advanced chronic kidney disease (CKD), involving dialysis or conservative care. Shared decision-making (SDM) is recommended as the model for decision-making in such preference-sensitive decisions. The aim of SDM is to come to decisions that are consistent with the patient’s values and preferences and made by the patient and healthcare professional working together. In clinical practice, however, SDM appears to be not yet routine and needs further implementation. A shift from a biomedical to a person-centered conception might help to make the process more shared. Shared should, therefore, be interpreted as two persons bringing two perspectives to the table, that both need to be explored during the decision-making process. Starting from the patient’s perspective will enable to determine the mutual goals of care first and, subsequently, determine the best way for achieving those goals. To perform such SDM, the healthcare professional needs to become a skilled companion, being part of the patient’s relational context, and start asking the right questions about what matters to the patient as person. In this article, we describe the need for a person-centered conception of SDM for the setting of older patients with advanced CKD.

Dialysis Organization Online Information on Kidney Failure Treatments: A Content Analysis Using Corpus Linguistics

Rationale & Objective

Dialysis organizations’ websites may influence patient decision making, but the websites have received almost no consideration. We investigated how/whether these websites present all kidney replacement therapy options and how the quality of life of these options is portrayed.

Study Design

Content analysis using corpus linguistics (computer-assisted language analysis).

Setting

Website content aimed at patients from the 2 major dialysis organizations’ websites, totaling 226,968 words. The analysis took place from November 12, 2020, to March 30, 2021.

Analytical Approach

We used linguistic software (AntConc) to document the frequencies of words needed to present treatment options and quality of life information.

Results

Over both sites, dialysis mentions outstripped transplantation mentions. Organization A did not appear to reference conservative kidney management. Organization B mentioned dialysis more often than conservative management, at a ratio of 34:1. Organization A did not attribute symptoms to dialysis, whereas organization B had 12 mentions of dialysis-induced symptoms out of 87 total symptom references. Both organizations framed life on dialysis optimistically, suggesting that patients can continue to engage in “work,” “sex,” or “travel”; organization A referenced sex, work, and/or travel 123 times and organization B referenced these 262 times.

Limitations

We used quantitative analysis and linked ideas with certain keywords. We did not conduct a detailed qualitative inquiry.

Conclusions

The websites emphasized dialysis as a treatment for kidney failure, and the quality of life on dialysis was framed very optimistically. Qualitative studies of treatment modalities and the quality of life on dialysis in the patient-targeted material of dialysis organizations are needed.

A randomized controlled trial to evaluate and assess the effect of comprehensive pre-end stage kidney disease education on home dialysis use in veterans, rationale and design

BACKGROUND

Informed dialysis selection and greater home dialysis use are the two long-desired, underachieved targets of advanced chronic kidney disease (CKD) care in the US healthcare system. Observational institutional studies have shown that comprehensive pre-kidney failure, conventionally referred to as end stage kidney disease education (CPE) can improve both these outcomes. However, lack of validated protocols, well-controlled studies, and systemic models have limited wide-spread adoption of CPE in the US. We hypothesized that a universal CPE and patient-centered initiation of kidney replacement therapy can improve multiple clinical, patient-centered and health service outcomes in advanced CKD and kidney failure requiring dialysis therapy.

METHODS

Trial to Evaluate and Assess the effects of CPE on Home dialysis in Veterans (TEACH-VET) is a multi-method randomized controlled trial aimed to evaluate the effects of a system-based approach for providing CPE to all Veterans with advanced CKD across a regional healthcare System. The study will randomize 544 Veterans with non-dialysis stage 4 and 5 CKD in a 1:1 allocation stratified by their annual family income and the stage of CKD to an intervention (CPE) arm or control arm. Intervention arm will receive a two-phase CPE in an intent-to-teach manner. Control arm will receive usual clinical care supplemented by resources for the freely-available kidney disease information. Participants will be followed after intervention/control for the duration of the study or until 90-days post-kidney failure, whichever occurs earlier.

RESULTS

The primary outcome will assess the proportion of Veterans using home dialysis at 90-days post-kidney failure, and secondary outcomes will include post-intervention/control CKD knowledge, confidence in dialysis decision and home dialysis selection. Qualitative arm of the study will use semi-structured interviews to in-depth assess Veterans' satisfaction with the intervention, preference for delivery, and barriers and facilitators to home dialysis selection and use. Several post-kidney failure clinical, patient-centered and health services outcomes will be assessed 90-days post-kidney failure as additional secondary outcomes.

CONCLUSION

The results will provide evidence regarding the need and efficacy of a system-based, patient-centered approach towards universal CPE for all patients with advanced CKD. If successful, this may provide a blueprint for developing such programs across the similar healthcare infrastructures throughout the country.

TRIAL REGISTRATION

NCT04064086 .

A Systematic Literature Review of Relational Autonomy in Dialysis Decision Making

Nephrology interdisciplinary guidelines, professional codes of ethics, principle-based ethical standards, and literature promote patient autonomy and self-determination through shared decision making as ethical practice. Healthcare professionals are accountable for practice that is mindful of the impact of cultural diversity and community on the values and beliefs of the patient, an important part of shared decision making (SDM). Despite previous research regarding dialysis decision making, relational autonomy in chronic kidney disease (CKD) and end-stage kidney disease SDM conversations is not well understood. This systematic literature review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework for identifying peer-reviewed literature on SDM for CKD. The findings were summarized into four broad themes: (1) promoting autonomy is a foundation of medical caring; (2) providers have a responsibility to respond to their asymmetrical social power; (3) autonomy is situated within the context of the patient; and (4) dialogue is a tool that negotiates clinical recommendations and patient goals. The caring practices of promoting autonomy with a dialogical resolution of a conflict acknowledging the interdependence of the parties and the patient's social-relational situatedness support a perspective of relational autonomy in dialysis decision-making practice and research.

Integrating Conservative kidney management Options and advance care Planning Education (COPE) into routine CKD care: a protocol for a pilot randomised controlled trial

INTRODUCTION

Predialysis education for patients with advanced chronic kidney disease (CKD) typically focuses narrowly on haemodialysis and peritoneal dialysis as future treatment options. However, patients who are older or seriously ill may not want to pursue dialysis and/or may not benefit from this treatment. Conservative kidney management, a reasonable alternative treatment, and advance care planning (ACP) are often left out of patient education and shared decision-making. In this study, we will pilot an educational intervention (Conservative Kidney Management Options and Advance Care Planning Education-COPE) to improve knowledge of conservative kidney management and ACP among patients with advanced CKD who are older and/or have poor functional status.

METHODS AND ANALYSIS

This is a single-centre pilot randomised controlled trial at an academic centre in Philadelphia, PA. Eligible patients will have: age ≥70 years and/or poor functional status (as defined by Karnofsky Performance Index Score <70), advanced CKD (estimated glomerular filtration rate<20 mL/min/1.73 m²), prefer to speak English during clinical encounters and self-report as black or white race. Enrolled patients will be randomised 1:1, with stratification by race, to receive enhanced usual care or usual care and in-person education about conservative kidney management and ACP (COPE). The primary outcome is change in knowledge of CKM and ACP. We will also explore intervention feasibility and acceptability, change in communication of preferences and differences in the intervention's effects on knowledge and communication of preferences by race. We will assess outcomes at baseline, immediately post-education and at 2 and 12 weeks.

ETHICS AND DISSEMINATION

This protocol has been approved by the Institutional Review Board at the University of Pennsylvania. We will obtain written informed consent from all participants. The results from this work will be presented at academic conferences and disseminated through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

This trial is registered at ClinicalTrials.gov under NCT03229811.

"Please Keep Mom Alive One More Day"-Clashing Directives of a Dying Patient and Her Surrogate

All medical care providers are legally and ethically bound to respect their patients' wishes. However, as patients lose decision-making capacity and approach end of life, their families or surrogates, who are confronted with grief, fear, self-doubt, and/or uncertainty, may ask physicians to provide treatment that contradicts the patients' previously stated wishes. Our work discusses the legal and ethical issues surrounding such requests and provides guidance for clinicians to ethically and compassionately respond-without compromising their professional and moral obligations to their patients.

Renal Replacement Therapy in Patients With Stage IV Cancer Admitted to the Intensive Care Unit With Acute Kidney Injury at a Comprehensive Cancer Center Was Not Associated With Survival

INTRODUCTION

In patients with advanced cancer, prolongation of life with treatment often incurs substantial emotional and financial expense. Among hospitalized patients with cancer since acute kidney injury (AKI) is known to be associated with much higher odds for hospital mortality, we investigated whether renal replacement therapy (RRT) use in the intensive care unit (ICU) was a significant independent predictor of worse outcomes.

METHODS

We retrospectively reviewed patients admitted in 2005 to 2014 who were diagnosed with stage IV solid tumors, had AKI, and a nephrology consult. The main outcomes were survival times from the landmark time points, inpatient mortality, and longer term survival after hospital discharge. Logistic regression and Cox proportional regression were used to compare inpatient mortality and longer term survival between RRT and non-RRT groups. Propensity score-matched landmark survival analyses were performed with 2 landmark time points chosen at day 2 and at day 7 from ICU admission.

RESULTS

Of the 465 patients with stage IV cancer admitted to the ICU with AKI, 176 needed RRT. In the multivariate logistic regression model after adjusting for baseline serum albumin and baseline maximum Sequential Organ Failure Assessment (SOFA), the patients who received RRT were not significantly different from non-RRT patients in inpatient mortality (odds ratio: 1.004 [95% confidence interval: 0.598-1.684], P = .9892). In total, 189 patients were evaluated for the impact of RRT on long-term survival and concluded that RRT was not significantly associated with long-term survival after discharge for patients who discharged alive. Landmark analyses at day 2 and day 7 confirmed the same findings.

CONCLUSIONS

Our study found that receiving RRT in the ICU was not significantly associated with inpatient mortality, survival times from the landmark time points, and long-term survival after discharge for patients with stage IV cancer with AKI.

What do the US advanced kidney disease patients want? Comprehensive pre-ESRD Patient Education (CPE) and choice of dialysis modality

Improvement in Home Dialysis (HoD) utilizations as a mean to improve the patient reported and health services outcomes, has been a long-held goal of the providers and healthcare system in United States. However, measures to improve HoD rates have yielded limited success so far. Lack of patient awareness of chronic kidney disease (CKD) and its management options, is one of the important barriers against patient adoption of HoD. Despite ample evidence that Comprehensive pre-ESERD Patient Education (CPE) improves patient awareness and informed HoD choice, use of CPE among US advanced CKD patients is low. Need for significant resources, lack of validated data showing unequivocal and reproducible benefits, and the lack of validated CPE protocols proven to have consistent efficacy in improving not only patient awareness but also HoD rates in US population, are major limitations deterring adoption of CPE in routine clinical practice. We recently demonstrated that if a structured, protocol based CPE is integrated within the routine nephrology care for patients with advanced CKD, it substantially improves informed HoD choice and utilizations. However, this requires establishing CPE resources within each nephrology practice. Efficacy of a stand-alone CPE model, independent of clinical care, has not been examined till date. In this report we report the efficacy of our structured CPE protocol, delivered outside the realm of routine nephrology care-as a stand-alone patient education program, in a geographically distant region, and show that: when provided opportunity for informed dialysis choice, a majority of advanced CKD patients in US would prefer HoD. We also show that initiating CPE leads to accelerated growth in HoD utilizations and reduces disparities in HoD utilizations, goals for system improvements. Finally, the reproducibility of our structured CPE protocol with consistent efficacy data suggest that initiating such programs at institutional levels has the potential to improve informed dialysis selection and HoD rates across any similar large healthcare institute within US.

Shared decision-making in advanced chronic kidney disease in the elderly

Chronic kidney disease is common in people >65years of age. The development and improvement of dialysis techniques has allowed its generalisation to the entire population, when there is a situation of terminal nephropathy, without limit of use due to chronological age. Decision making in elderly patients with advanced chronic kidney disease is complex: in addition to renal parameters, both comorbidity and the presence of geriatric syndromes must be considered. This review addresses the management of information, the decision making of different treatment modalities that can be offered to these patients, and the time of initiation and/or withdrawal of dialysis.

Longitudinal patterns of health-related quality of life and dialysis modality: a national cohort study

Background

Health-related quality of life (HrQoL) varies among dialysis patients. However, little is known about the association of dialysis modality with HrQoL over time. We describe longitudinal patterns of HrQoL among chronic dialysis patients by treatment modality.

Methods

National retrospective cohort study of adult patients who initiated in-center dialysis or a home modality (peritoneal or home hemodialysis) between 1/2013 and 6/2015. Patients remained on the same modality for the first 120 days of the first two years. HrQoL was assessed by the Kidney Disease and Quality of Life-36 (KDQOL) survey in the first 120 days of the first two years after dialysis initiation. Home modality patients were matched to in-center patients in a 1:5 fashion.

Results

In-center (n=4234) and home modality (n=880) patients had similar demographic and clinical characteristics. In-center dialysis patients had lower mean KDQOL scores across several domains compared to home modality patients. For patients who remained on the same modality, there was no change in HrQoL. However, there were trends towards clinically meaningful changes in several aspects of HrQoL for patients who switched modalities. Specifically, physical functioning decreased for patients who switched from home to in-center dialysis (p< 0.05).

Conclusions

Among a national cohort of chronic dialysis patients, there was a trend towards different patterns of HrQoL life that were only observed among patients who changed modality. Patients who switched from home to in-center modalities had significant lower physical functioning over time. Providers and patients should be mindful of HrQoL changes that may occur with dialysis modality change.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1198-5) contains supplementary material, which is available to authorized users.

Barriers to Advance Care Planning in End-Stage Renal Disease: Who is to Blame, and What Can be Done?

Patients with end-stage renal disease experience significant mortality and morbidity, including cognitive decline. Advance care planning has been emphasized as a responsibility and priority of physicians caring for patients with chronic kidney disease in order to align with patient values before decision-making capacity is lost and to avoid suffering. This emphasis has proven ineffective, as illustrated in the case of a patient treated in our hospital. Is this ineffectiveness a consequence of failure in the courtroom or the clinic? Through our own experience we affirm what has been written before: that legal precedent favors intensive treatment in virtually all cases without 'clear and convincing evidence' of a patient's previously declared wishes to the contrary. Equally clear is that more than 20 years of support in the clinical literature suggesting advance care planning early in the course of disease can address challenges in the legal system for those lacking capacity. However, many physicians fail to recognize the need for advance care planning in a timely manner and lack the necessary training to provide it. The need for more training and new tools to recognize opportunities for advance care planning in daily practice remains unmet.

[Ethical issues perceived by health care professionals working in chronic hemodialysis centers]

BACKGROUND

Clinical teams working at chronic hemodialysis centers (CHC) frequently have to face ethical problems, but there is no systematic approach to deal with them.

AIM

To study the ethical problems perceived by health professionals at CHC.

MATERIAL AND METHODS

Eighty randomly selected physicians and 139 nurses from 23 CHC, answered a structured questionnaire, devised by the research team.

RESULTS

Twenty-six percent of respondents had postgraduate studies in clinical ethics. The ethical problems mentioned by respondents were therapeutic disproportion in 66.7%, lack of communication between patients, their families and the clinical team in 25.9%, personal conflicts of interests related with hemodialysis prescription in 14.6% and conflicts of interests of other members of the clinical team in 30.6%. The percentage of respondents that experienced not starting or discontinuing hemodialysis treatment due to decision of patients’ relatives was 86.8%. Only 45.2% of health professionals had the opportunity to take part in decision-making meetings. Eighty seven percent of respondents supported the use of advanced directives in the event of a cardio respiratory arrest during treatment.

CONCLUSIONS

To improve the approach to ethical problems in CHC, it is necessary to improve training in clinical ethics, promote an effective dialogue between the patients, their families and health professionals, and follow their advance directives in case of cardiac arrest during treatment.

The Full Spectrum of Clinical Ethical Issues in Kidney Failure. Findings of a Systematic Qualitative Review

BACKGROUND

When treating patients with kidney failure, unavoidable ethical issues often arise. Current clinical practice guidelines some of them, but lack comprehensive information about the full range of relevant ethical issues in kidney failure. A systematic literature review of such ethical issues supports medical professionalism in nephrology, and offers a solid evidential base for efforts that aim to improve ethical conduct in health care.

AIM

To identify the full spectrum of clinical ethical issues that can arise for patients with kidney failure in a systematic and transparent manner.

METHOD

A systematic review in Medline (publications in English or German between 2000 and 2014) and Google Books (with no restrictions) was conducted. Ethical issues were identified by qualitative text analysis and normative analysis.

RESULTS

The literature review retrieved 106 references that together mentioned 27 ethical issues in clinical care of kidney failure. This set of ethical issues was structured into a matrix consisting of seven major categories and further first and second-order categories.

CONCLUSIONS

The systematically-derived matrix helps raise awareness and understanding of the complexity of ethical issues in kidney failure. It can be used to identify ethical issues that should be addressed in specific training programs for clinicians, clinical practice guidelines, or other types of policies dealing with kidney failure.

The Evolving Ethics of Dialysis in the United States: A Principlist Bioethics Approach

Throughout the history of dialysis, four bioethical principles - beneficence, nonmaleficence, autonomy and justice - have been weighted differently based upon changing forces of technologic innovation, resource limitation, and societal values. In the 1960s, a committee of lay people in Seattle attempted to fairly distribute a limited number of maintenance hemodialysis stations guided by considerations of justice. As technology advanced and dialysis was funded under an amendment to the Social Security Act in 1972, focus shifted to providing dialysis for all in need while balancing the burdens of treatment and quality of life, supported by the concepts of beneficence and nonmaleficence. At the end of the last century, the importance of patient preferences and personal values became paramount in medical decisions, reflecting a focus on the principle of autonomy. More recently, greater recognition that health care financial resources are limited makes fair allocation more pressing, again highlighting the importance of distributive justice. The varying application and prioritization of these four principles to both policy and clinical decisions in the United States over the last 50 years makes the history of hemodialysis an instructive platform for understanding principlist bioethics. As medical technology evolves in a landscape of changing personal and societal values, a comprehensive understanding of an ethical framework for evaluating appropriate use of medical interventions enables the clinician to systematically negotiate and optimize difficult ethical situations.

A Survey of Physicians' Attitudes toward Decision-Making Authority for Initiating and Withdrawing VA-ECMO: Results and Ethical Implications for Shared Decision Making

OBJECTIVE

Although patients exercise greater autonomy than in the past, and shared decision making is promoted as the preferred model for doctor-patient engagement, tensions still exist in clinical practice about the primary locus of decision-making authority for complex, scarce, and resource-intensive medical therapies: patients and their surrogates, or physicians. We assessed physicians' attitudes toward decisional authority for adult venoarterial extracorporeal membrane oxygenation (VA-ECMO), hypothesizing they would favor a medical locus.

DESIGN, SETTING, PARTICIPANTS

A survey of resident/fellow physicians and internal medicine attendings at an academic medical center, May to August 2013.

MEASUREMENTS

We used a 24-item, internet-based survey assessing physician-respondents' demographic characteristics, knowledge, and attitudes regarding decisional authority for adult VA-ECMO. Qualitative narratives were also collected.

MAIN RESULTS

A total of 179 physicians completed the survey (15 percent response rate); 48 percent attendings and 52 percent residents/fellows. Only 32 percent of the respondents indicated that a surrogate's consent should be required to discontinue VA-ECMO; 56 percent felt that physicians should have the right to discontinue VA-ECMO over a surrogate's objection. Those who self-reported as "knowledgeable" about VA-ECMO, compared to those who did not, more frequently replied that there should not be presumed consent for VA-ECMO (47.6 percent versus 33.3 percent, p = 0.007), that physicians should have the right to discontinue VA-ECMO over a surrogate's objection (76.2 percent versus 50 percent, p = 0.02) and that, given its cost, the use of VA-ECMO should be restricted (81.0 percent versus 54.4 percent, p = 0.005).

CONCLUSIONS

Surveyed physicians, especially those who self-reported as knowledgeable about VA-ECMO and/or were specialists in pulmonary/critical care, favored a medical locus of decisional authority for VA-ECMO. VA-ECMO is complex, and the data may (1) reflect physicians' hesitance to cede authority to presumably less knowledgeable patients and surrogates, (2) stem from a stewardship of resources perspective, and/or (3) point to practical efforts to avoid futility and utility disputes. Whether these results indicate a more widespread reversion to paternalism or a more circumscribed usurping of decisional authority occasioned by VA-ECMO necessitates further study.

[Conservative treatment, hemodialysis or peritoneal dialysis for elderly patients: The choice of treatment does not influence the survival]

Hemodialysis is the predominant replacement therapy in the 70 year-old French population (18% in peritoneal dialysis, 72% in hemodialysis from the REIN registry). Managing older patients reaching the end stage renal disease poses many ethical questions, since outcomes balanced regarding survival and quality of life. The aim of this study was to compare the survival of patients aged over 70 years according to the ESRD treatment choice: conservative treatment without dialysis (CT), hemodialysis (HD) and peritoneal dialysis (PD). We included all patients over 70 years reaching stade IV CKD integrated in a predialysis information program between 01/01/2005 and 31/12/2010. We compared their survival from the start of their program, in function of their treatment choice: HD, PD or CT. On this period, 148 patients were included, we excluded from analysis 17 patients who had a contraindication to PD, 26 patients who did not make a choice because their kidney function was stabilized, 4 patients lost to follow-up and 12 patients who died before the treatment choice. The average age was 79±6 years, 40% of patients were women, and the mean eGFR was 16±9 mL/min/1.73 m(2) at the entry in the program. Among the 89 patients, 21 choose CT (24%), 68 accepted dialysis (76%), including 48 HD (71%) and 20 PD (29%). No significant eGFR difference at the inclusion time between the groups. The time initiation of dialysis was significantly shorter in the PD group (146 days vs 442 in the HD group; P=0.004). Survival between the groups of patients who accepted or refused dialysis was not statistically different (749 days or 2 years in the HD + PD group vs 562 days, or 1 year and 6 months in the CT group; P=0.95) and between the HD group (760 days or 2 years and 2 months) and the PD group (343 days or 11 months; P=0.32). As measured from the time they entered in the predialysis program, the survival of older patients over 70 years does not seem to depend on their choice of treatment modality. Whether they accepted or refused dialysis, whatever their choice concerning hemodialysis or peritoneal dialysis, their survival was close to one year.

Sustaining life or prolonging dying? Appropriate choice of conservative care for children in end-stage renal disease: an ethical framework

Due to technological advances, an increasing number of infants and children are surviving with multi-organ system dysfunction, and some are reaching end-stage renal disease (ESRD). Many have quite limited life expectancies and may not be eligible for kidney transplantation but families request dialysis as alternative. In developed countries where resources are available there is often uncertainty by the medical team as to what should be done. After encountering several of these scenarios, we developed an ethical decision-making framework for the appropriate choice of conservative care or renal replacement therapy in infants and children with ESRD. The framework is a practical tool to help determine if the burdens of dialysis would outweigh the benefits for a particular patient and family. It is based on the four topics approach of medical considerations, quality-of-life determinants, patient and family preferences and contextual features tailored to pediatric ESRD. In this article we discuss the basis of the criteria, provide a practical framework to guide these difficult conversations, and illustrate use of the framework with a case example. While further research is needed, through this approach we hope to reduce the moral distress of care providers and staff as well as potential conflict with the family in these complex decision-making situations.

Fragmented care and whole-person illness: Decision-making for people with chronic end-stage kidney disease

PURPOSE

The study reported herein sought to better understand how patients with multi-morbid, chronic illness-who receive care in institutions designed for treatment of acute illness-experience and engage in health-related decisions.

METHODS

In an urban Canadian teaching hospital, we studied the interactions of six hemodialysis patients and 11 of the health professionals involved in their care. For 1 year (September 2009 to September 2010), we conducted ethnographic observation and interviews of six cases each comprising one hemodialysis patient and various health professionals including medical specialists, nurses, a social worker, and a dietician.

RESULTS

We found that the ubiquity and complexity of health-related decision-making in the lives of these patients suggests the need for a more holistic interpretation of health-related decision-making.

DISCUSSION

We propose an interpretation of decision-making as an ongoing process of integrating illness and life; as frequently open-ended, cumulative, and relational; and as fundamentally shaped by the fragmented delivery of care for patients with multiple morbidities.

CONCLUSION

Our understanding of decision-making suggests that people living with complex chronic illness need to receive care from institutions that recognize and address their multi-morbidity as a whole illness that is constantly being integrated into the life of a whole person.

Should dialysis be offered to all elderly patients?

Nephrologist are often faced with the question of the appropriate initiation and withdrawal from dialysis. Many clinicians feel that patient should be offered dialysis when they have ESRD regardless of the potential risks vs. benefits. My position in this debate is that nephrologists have the obligation to order treatments that are indicated and effective for their patients and will provide more benefit that harm. They should not order dialysis in patient that are not likely to benefit from the treatment. Patients have the right to refuse treatments but not the right to demand that a clinician order an ineffective treatment. Shared decision making is the key principle in deciding on the initiation and withdrawal from dialysis. The national guideline; Shared Decision Making: The Appropriate Initiation and Withdrawal from Dialysis supports this approach.

Ethical challenges with hemodialysis patients who lack decision-making capacity: behavioral issues, surrogate decision-makers, and end-of-life situations

Hemodialysis (HD) is routinely offered to patients with end-stage renal disease in the United States who are ineligible for other renal replacement modalities. The frequency of HD among the US population is greater than all other countries, except Taiwan and Japan. In US, patients are often dialyzed irrespective of age, comorbidities, prognosis, or decision-making capacity. Determination of when patients can no longer dialyze is variable and can be dialysis-center specific. Determinants may be related to progressive comorbidities and frailty, mobility or access issues, patient self-determination, or an inability to tolerate the treatment safely for any number of reasons (e.g., hypotension, behavioral issues). Behavioral issues may impact the safety of not only patients themselves, but also those around them. In this article the authors present the case of an elderly patient on HD with progressive cognitive impairment and combative behavior placing him and others at risk of physical harm. The authors discuss the medical, ethical, legal, and psychosocial challenges to care of such patients who lack decision-making capacity with a focus on variable approaches by regions and culture. This manuscript provides recommendations and highlights resources to assist nephrologists, dialysis personnel, ethics consultants, and palliative medicine teams in managing such patients to resolve conflict.

Decision making in elderly patients with advanced kidney disease

Because the fastest-growing group of patients undergoing dialysis is older than 75 years, geriatricians will be more involved in decisions regarding the appropriate treatment of end-stage renal disease. A thoughtful approach to shared decision making regarding dialysis or nondialysis medical therapy (NDMT) includes consideration of medical indications, patient preferences, quality of life, and contextual features. Determination of prognosis and expected performance on dialysis based on disease trajectories and assessment of functional age should be shared with patients and families. The Renal Physician Association's guidelines on shared decision making in dialysis offer recommendations to help with dialysis or NDMT decisions.

Ethics and health policy of dialyzing a patient in a persistent vegetative state

Each year, out-of-hospital cardiac arrests occur in approximately 300,000 Americans. Of these patients, less than 10% survive. Survivors often live with neurologic impairments that neurologists classify as anoxic-ischemic encephalopathy (AIE). Neurologic impairments under AIE can vary widely, each with unique outcomes. According to the American Academy of Neurology Practice Parameter paper, the definition of poor outcome in AIE includes death, persistent vegetative state (PVS), or severe disability requiring full nursing care 6 months after event. In a recent survey, participants deemed an outcome of PVS as "worse than dead." Lay persons' assessments of quality of life for those in a PVS provide assistance for surrogate decision-makers who are confronted with the clinical decision-making for a loved one in a PVS, whereas clinical practice guidelines help health care providers to make decisions with patients and/or families. In 2000, the Renal Physicians Association and the American Society of Nephrology published a clinical practice guideline, "Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis." In 2010, after advances in research, a second edition of the guideline was published. The updated guideline confirmed the recommendation to withhold or withdraw ongoing dialysis in "patients with irreversible, profound neurological impairments such that they lack signs of thought, sensation, purposeful behavior and awareness of self and environment," such as found in patients with PVS. Here, the authors discuss the applicability of this guideline to patients in a PVS. In addition, they build on the guideline's conception of shared decision-making and discuss how continued dialysis violates ethical and legal principles of care in patients in a PVS.

Decision-making in patients with cancer and kidney disease

Thoughtful decision-making in a patient with cancer and kidney disease requires a comprehensive discussion of prognosis and therapy options for both conditions framed by the individual's preferences and goals of care. An estimate of overall prognosis is generated that includes the patient's clinical presentation and parameters associated with adverse outcomes, such as age, performance status, frailty, malnutrition, and comorbidities. Empathic communication of this information using a shared decision-making approach can lead to an informed decision that respects patient autonomy and is consistent with the patient's "big-picture" goals and personal values.

Beyond the futility argument: the fair process approach and time-limited trials for managing dialysis conflict

Futility is an ancient concept arising from Greek mythology that was resurrected for its medical application in the 1980s with the proliferation of many lifesaving technologies, including dialysis and renal transplantation. By that time, the domineering medical paternalism that characterized the pre-1960s physician-patient relationship morphed into assertive patient autonomy, and some patients began to claim the right to demand aggressive, high-technology interventions, despite physician disapproval. To counter this power struggle, the establishment of a precise definition of futility offered hope for a futility policy that would allow physicians to justify withholding or withdrawing treatment, despite patient and family objections. This article reviews the various attempts made to define medical futility and describes their limited applicability to dialysis. When futility concerns arise, physicians should recognize the opportunity to address conflict, using best practice communication skills. Physicians would also benefit from understanding the ethical principles of respect for patient autonomy, beneficence, nonmaleficence, justice, and professional integrity that underlie medical decision-making. Also reviewed is the use of a fair process approach or time-limited trial when conflict resolution cannot be achieved. These topics are addressed in the Renal Physician Association's clinical practice guideline Shared Decision-Making in the Appropriate Initiation and Withdrawal from Dialysis, with which nephrologists should be well versed. A case presentation of intractable calciphylaxis in a new dialysis patient illustrates the pitfalls of physicians not fully appreciating the ethics of medical decision-making and failing to use effective conflict management approaches in the clinical practice guideline.

Dialysis by the book? Treatment of renal failure in a 101-year-old patient

While dialysis historically began as treatment intended for younger patients, it has, over time, increasingly been extended to treat elderly patients with a high comorbidity burden. Data on the outcomes of dialysis in these patients show that in some cases it confers no benefit and may be associated with functional decline. We describe a 101-year-old male patient with chronic kidney disease (CKD), admitted to the intensive care unit (ICU) with exacerbation of heart failure and sepsis. He experienced acute deterioration of renal function, with oliguria and acidosis. The patient's healthcare proxy insisted that dialysis be initiated despite his extremely advanced age, citing the patient's devout religious beliefs. He underwent 56 dialysis treatments over the course of ∼4 months after which he died as a result of septic and cardiogenic shock. Our case is unique, in that it may represent the oldest individual ever reported to start haemodialysis. It illustrates the ever-growing clinical and ethical challenges posed by the treatment of renal failure in the geriatric population.

Nephrologists' professional ethics in dialysis practices

Although the number of incidents is unknown, professional quality-oriented renal organizations have become aware of an increased number of complaints regarding nephrologists who approach patients with the purpose of influencing patients to change nephrologists or dialysis facilities (hereinafter referred to as patient solicitation). This development prompted the Forum of ESRD Networks and the Renal Physicians Association to publish a policy statement on professionalism and ethics in medical practice as these concepts relate to patient solicitation. Also common but not new is the practice of nephrologists trying to recruit their own patients to a new dialysis unit in which they have a financial interest. This paper presents two illustrative cases and provides an ethical framework for analyzing patient solicitation and physician conflict of interest. This work concludes that, in the absence of objective data that medical treatment is better elsewhere, nephrologists who attempt to influence patients to change nephrologists or dialysis facilities fall short of accepted ethical standards pertaining to professional conduct, particularly with regard to the physician-patient relationship, informed consent, continuity of care, and conflict of interest.

Advance care planning in CKD/ESRD: an evolving process

Advance care planning was historically considered to be simply the completion of a proxy (health care surrogate designation) or instruction (living will) directive that resulted from a conversation between a patient and his or her physician. We now know that advance care planning is a much more comprehensive and dynamic patient-centered process used by patients and families to strengthen relationships, achieve control over medical care, prepare for death, and clarify goals of care. Some advance directives, notably designated health care proxy documents, remain appropriate expressions of advance care planning. Moreover, although physician orders, such as do-not-resuscitate orders and Physician Orders for Life-Sustaining Treatment, may not be strictly defined as advance directives, their completion, when appropriate, is an integral component of advance care planning. The changing health circumstances and illness trajectory characteristic of ESRD mandate that advance care planning discussions adapt to a patient's situation and therefore must be readdressed at appropriate times and intervals. The options of withholding and withdrawing dialysis add ESRD-specific issues to advance care planning in this population and are events each nephrologist will at some time confront. Advance care planning is important throughout the spectrum of ESRD and is a part of nephrology practice that can be rewarding to nephrologists and beneficial to patients and their families.