Practical ethical issues of dialysis in the elderly

Area of Science:

• Nephrology
• Geriatrics
• Public Health

Background:

• The number of elderly patients requiring dialysis is increasing globally due to relaxed acceptance criteria and an aging population.
• Hypertension and diabetes are primary causes of end-stage renal disease (ESRD) in older adults, though renal disease etiology remains unknown in many cases.
• Hospital hemodialysis is the predominant renal replacement therapy (RRT) for the elderly.

Purpose of the Study:

• To review the challenges and considerations in the treatment of elderly patients with end-stage renal disease (ESRD).
• To examine the specific complications, quality of life, and mortality rates associated with dialysis in the elderly population.
• To discuss the ethical dilemmas and resource allocation issues pertinent to ESRD treatment in older adults.

Main Methods:

• Review of literature and data, including the US Renal Data System (USRDS) reports.
• Analysis of vascular access types, complication rates, and treatment modalities (hemodialysis vs. peritoneal dialysis) in elderly dialysis patients.
• Examination of factors influencing quality of life, mortality, and ethical considerations in ESRD management for the elderly.

Main Results:

• Elderly hemodialysis patients exhibit higher access morbidity, with hypotension, arrhythmias, and gastrointestinal bleeding being common complications.
• Peritoneal dialysis offers home treatment feasibility for the elderly, with similar peritonitis and catheter complication rates compared to younger patients.
• Malnutrition incidence rises with age, and quality of life varies; mortality is higher in the elderly, primarily due to cardiovascular diseases and infections.

Conclusions:

• Adequate social support, particularly from family, is crucial for elderly patients undergoing chronic dialysis.
• ESRD treatment in the elderly presents significant ethical challenges, including concerns about cost, treatment futility, rationing, and withholding/withdrawing therapy.
• Limited healthcare resources often lead to the elderly being considered expendable, creating difficult dilemmas for nephrologists regarding treatment decisions.