Deciding not to start dialysis--a one year prospective study in Teesside

Area of Science:

• Nephrology
• Geriatric Medicine
• Medical Ethics

Background:

• End-stage renal failure (ESRF) necessitates renal replacement therapy (RRT), typically dialysis.
• Decisions regarding dialysis initiation for ESRF patients involve complex medical, social, and ethical considerations.
• Understanding patient selection for dialysis is crucial for resource allocation and patient care.

Purpose of the Study:

• To determine the characteristics of patients with presumed irreversible renal failure who were not commenced on dialysis.
• To identify the reasons behind the decision not to initiate dialysis.
• To compare these patients with those who did commence RRT.

Main Methods:

• A prospective, 12-month observational study was conducted.
• Data on decision-making processes were collected via proforma from physicians.
• Patient information was obtained from case notes.

Main Results:

• Eleven patients were not commenced on dialysis, versus 88 who started RRT.
• Undialysed patients were elderly (56-90 years, 60% ≥80), had significant co-morbidities, and often lacked prior renal care.
• Decision-making involved limited patient choice, with many patients deemed incapable of participating or unlikely to benefit due to imminent non-renal death.

Conclusions:

• A subset of patients with complex medical and social challenges are not selected for dialysis.
• While some patients might have had life prolonged by dialysis, many faced imminent death from non-renal causes.
• Patient involvement in the decision-making process for dialysis initiation was notably low.