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The Ethics of Chronic Dialysis for the Older Patient: Time to Reevaluate the Norms
Bjorg Thorsteinsdottir1, Keith M Swetz2, Robert C Albright3
1Department of Medicine, Division of Primary Care Internal Medicine, Biomedical Ethics Program, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota thorsteinsdottir.bjorg@mayo.edu.
Insights
Hemodialysis offers benefits but carries burdens for elderly patients with comorbidities. Shared decision-making and personalized care are crucial to avoid both overtreatment and ageist rationing of this therapy.
Area of Science:
- Nephrology
- Geriatrics
- Bioethics
Background:
- Older adults with comorbidities face significant burdens from hemodialysis, with unclear net benefits.
- Shifting healthcare payment models may disincentivize hemodialysis for high-risk elderly patients, raising concerns about undertreatment.
- Ethical considerations are paramount in balancing overtreatment and undertreatment of hemodialysis in the elderly.
Purpose of the Study:
- To address concerns regarding the overtreatment and potential undertreatment of hemodialysis in older adults with end-stage renal disease (ESRD).
- To guide nephrologists in ethically approaching hemodialysis initiation decisions for elderly patients.
- To emphasize the importance of patient-centered care and shared decision-making.
Main Methods:
- Review of current research on hemodialysis in elderly patients with comorbidities.
- Analysis of the impact of accountable care and bundled payment models on treatment decisions.
- Discussion of ethical frameworks for decision-making, including patient goals of care and prognosis.
Main Results:
- Clinical equipoise exists regarding the net benefits of hemodialysis for older patients with significant comorbidities.
- New payment models may lead to reduced hemodialysis rates in high-risk elderly populations.
- Patient-specific factors (age, function, nutrition, comorbidities) significantly influence the benefit-burden balance.
Conclusions:
- Nephrologists must respect patients' rights to informed consent regarding hemodialysis benefits and burdens.
- Shared decision-making, guided by patient goals, is essential for determining appropriate hemodialysis initiation.
- Utilizing palliative care and ethics consultations can aid complex cases involving elderly ESRD patients.
Abstract:
Recent research highlights the potential burdens of hemodialysis for older patients with significant comorbidities, for whom there is clinical equipoise regarding the net benefits. With the advent of accountable care and bundled payment, previous incentives to offer hemodialysis to as many patients as possible are being replaced with a disincentive to dialyze high-risk patients. While this may offset the harm of overtreatment for some elderly patients, some voice concerns that the pendulum will swing too far back, with a return to ageist rationing of hemodialysis. Nephrologists should ensure that the patient's rights to be informed about the potential benefits and burdens of hemodialysis are respected, particularly because age, functional status, nutritional status, and comorbidities affect the net balance between benefits and burdens. Nephrologists are also called on to help patients make a decision, for which the patient's goals of care guide determination of potential benefit from hemodialysis. This article addresses concerns about present overtreatment and future risk of undertreatment of older adults with ESRD. It also discusses ways in which providers can ethically approach the question of initiation of hemodialysis in the elderly patient by including patient-specific estimates of prognosis, shared decision-making, and the use of specialist palliative care clinicians or ethics consultants for complex cases.
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