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The very elderly dialysis patient: indication and discontinuation of dialysis
K Schaefer1, D von Herrath, J Faust
1St. Joseph-Krankenhaus, Medizinische Abteilung II, Bäumerplan 24, 12101 Berlin, Germany.
Insights
Excluding patients over 80 from chronic dialysis is medically inadvisable. Ethical considerations and patient autonomy, especially with advance directives (AD), are paramount in dialysis decisions for elderly individuals.
Area of Science:
- Nephrology
- Geriatrics
- Medical Ethics
Background:
- Literature review indicates a consensus against excluding patients over 80 from chronic dialysis for medical reasons.
- While cost savings are possible, elderly dialysis patients are not disproportionately expensive.
- Ethical justification for excluding octogenarians from dialysis is challenging.
Purpose of the Study:
- To summarize current literature regarding the exclusion of elderly patients from chronic dialysis.
- To analyze the ethical and practical considerations of withholding dialysis from patients over 80.
- To emphasize the importance of patient autonomy and advance directives in end-of-life care decisions for dialysis patients.
Main Methods:
- Comprehensive literature review and synthesis of existing data.
- Ethical analysis of age-based exclusion criteria for dialysis.
- Discussion of legal and familial aspects concerning patient autonomy and decision-making.
Main Results:
- The majority of available data supports the continuation of chronic dialysis for patients over 80.
- Patient refusal of dialysis requires informed consent; otherwise, decisions involve legal or surrogate consultation.
- Advance directives (AD) facilitate decision-making and serve as a form of care for families.
Conclusions:
- Excluding elderly patients over 80 from dialysis is medically and ethically questionable.
- Patient autonomy and informed consent are critical in dialysis decisions, regardless of age.
- Advance directives are valuable tools for guiding care and respecting patient wishes, particularly when essential care is considered for discontinuation.
Abstract:
1. When the current available data in the literature is summarized it becomes evident that the majority of it supports the position that it is, at least for medical reasons, not advisable to exclude patients over the age of 80 years from chronic dialysis. 2. It is correct to say that the refusal of dialysis therapy for elderly dialysis patients would lead to a not insignificant cutting of costs, although elderly patients are not as 'expensive' as younger dialysis patients. 3. The decision to exclude patients over 80 from dialysis treatment is difficult, in our opinion, to support ethically. 4. The refusal of therapy by a dialysis patient--independent of his age--can only occur with his/her consent, as long as the patient is clearly conscious of the decision. 5. Should the patient no longer be in the condition to exercise his/her autonomy, and there is no AD, the Surrogate's Court must be consulted. 6. AD can be seen as helpful, since they not only make the decisions for physicians easier, but also because they can be seen as an act of care for family members. 7. Whenever dialysis therapy is discontinued the problematic nature of so-called essential care should be carefully considered, especially if no clear position has been taken in an AD.
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