Dialysis

The number of older patients with end stage renal disease (ESRD) is increasing. Contributing factors are aging of the population, increasing prevalence of diabetes mellitus and hypertension, and earlier recognition and referral for ESRD.  In addition, the prevalence of chronic kidney disease (CKD) reaching end-stage renal disease (ESRD) increases with age. Increasing lifespan among ESRD patients is a primary reason for continued growth in the prevalent ESRD population. Approximately 40% of patients >75 years of age are affected by CKD, and dialysis initiation is highest in patients ≥65 years of age. Nearly fifty percent of all patients on dialysis are ages ≥65 years old in NY, including patients ≥85 years old.

Many patients who receive dialysis suffer from multiple comorbidities and/or frailty, and 1-year mortality rates following initiation of dialysis is 41% in patients ≥75 years of age overall. Dialysis patients often report feeling less independent, unable to participate in activities they enjoy and have an overall decline in functional status and quality of life. For those requiring custodial care in a skilled nursing facility, functional status is already diminished, and many have advanced frailty.

Frailty is a clinically recognizable state of older adults with increased vulnerability, resulting from age-associated declines in physiologic reserve and function across multiple organ systems, such that the ability to cope with every day or acute stressors is compromised. Assessment of functional status is recommended in Step 1 of the 8-Step MOLST Protocol and measured in eMOLST via use of the evidence-based Clinical Frailty Scale.

Renal Physicians Association (RPA) Recommendations

Since 1973 the RPA has been dedicated to representing and serving nephrology practitioners in their pursuit and delivery of quality renal health care. The “Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis” Clinical Practice Guideline uses research evidence, case and statutory law, and ethical principles in the formulation of the recommendations. RPA recommendations align with the 8-Step MOLST Protocol.

For Adult Patients

• Develop a physician-patient relationship for shared decision-making.
• Fully inform AKI, stage 4 and 5 CKD, and ESRD patients about their diagnosis, prognosis, and all treatment options.
• Give all patients with AKI, stage 5 CKD, or ESRD an estimate of prognosis specific to their overall condition.
• Institute advance care planning. Where legally accepted, POLST should be completed as part of the advance care planning process. In New York, this set of medical orders is called MOLST.
• If appropriate, forgo (withhold initiating or withdraw ongoing) dialysis for patients with AKI, CKD, or ESRD in certain, well-defined situations.
• Consider forgoing dialysis for AKI, CKD, or ESRD patients who have a very poor prognosis or for whom dialysis cannot be provided safely.
• Consider a time-limited trial of dialysis for patients requiring dialysis, but who have an uncertain prognosis, or for whom a consensus cannot be reached about providing dialysis.
• Establish a systematic due process approach for conflict resolution if there is disagreement about what decision should be made with regard to dialysis.
• To improve patient-centered outcomes, offer palliative care services and interventions to all AKI, CKD, and ESRD patients who suffer from burdens of their disease.
• Use a systematic approach to communicate about diagnosis, prognosis, treatment options, and goals of care. The 8-Step MOLST Protocol, developed and used since 2005, aligns with this recommendation.

For Pediatric Patients

• RPA recommendations for pediatric and adult patients align.
• Specific consideration is given to the minor patient who has capacity to make MOLST decision that aligns with FHCDA, as illustrated below.
• Forgo dialysis if initiating or continuing dialysis is deemed to be harmful, of no benefit, or merely prolongs a child’s dying process. The decision to
• forgo dialysis must be made in consultation with the child’s parents. Give children and adolescents the opportunity to participate in the decision to forgo dialysis to the extent that their developmental abilities and health status allow.

Treatment Options for Those Who Choose No Dialysis

Patients with an anticipated poor prognosis due to multiple comorbidities and/or advanced frailty may choose to forgo dialysis and decide to be treated conservatively instead. Unfortunately, many of them are never given the option.

Conservative management (CM) does not equate to “No Treatment.” Rather, CM entails ongoing care with full medical treatment, including control of fluid and electrolyte balance, correcting anemia, and provision of appropriate palliative and end of life care. Conservative management includes a care plan that treats symptoms and supports the patient and caregivers holistically.

MOLST

Shared decision making is recommended to come to a joint decision on dialysis by considering potential benefits and harms of all treatment options and the patient’s preferences based on the patient’s goals for care.  Appropriate provision of palliative care and end-of-life care in these clinical situations requires a thoughtful MOLST discussion and medical orders regarding dialysis documented on page 2 of the MOLST Form in “Other Instructions”.

References

Renal Physicians Association. Shared Decision-Making in the Appropriate Initiation and Withdrawal from Dialysis: Clinical Practice Guideline, 2nd ed. Rockville, MD: Renal Physicians Association, 2010.

US Renal Data System 2019 Annual Data Report: Epidemiology of Kidney Disease in the United States https://www.usrds.org/2019/download/USRDS_2019_ES_final.pdf

Rak A, Raina R, Suh T, et al. Palliative care for patients with end-stage renal disease: approach to treatment that aims to improve quality of life and relieve suffering for patients (and families) with chronic illnesses. Clin Kidney J.  2017 Feb; 10(1): 68-73.

Verberne WR, Geers T, Jellema WT, et al. Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis Clin J Am Soc Nephrol 2016; 11: 1-8.

Content developed in collaboration with Indra D. Daniels MD, Attending Physician, Palliative Care Division, Nephrology and Hospice & Palliative Medicine; Clinical Assistant Professor, Icahn School of Medicine Mount Sinai South Nassau.