Should You Ever Say \'No\' to Dialysis??>

Should You Ever Say 'No' to Dialysis?

by Alice Lesch Kelly  

For people with kidney failure, dialysis can be a lifesaving therapy. While dialysis is tiring and time-consuming, most patients feel that the life-extending benefits of dialysis far outweigh its burdens. But some elderly, frail patients with advanced chronic kidney disease may experience a significant decline in their quality of life after initiating dialysis and prefer not to take on its burdens.

A recent study, published in January 2019 in JAMA Internal Medicine, found that patients with advanced chronic kidney disease who choose not to start dialysis may struggle to get their doctors to respect their wishes. The study, which analyzed medical records from 851 men and 9 women (average age 75) receiving care from the VA between 2000 and 2011, found that “dialysis is often framed to patients as a necessity rather than a treatment choice.”

While this study was limited to VA hospitals and might not be consistent with practices at non-VA facilities, the finding does raise concern that some elderly patients with end-stage kidney disease, especially those with other life-limiting illnesses, might not realize that initiating dialysis may offer little, if any, improvement in the quality of their life at this stage and they have the choice to turn dialysis down. In fact, clinical guidelines emphasize shared decision making between patients and doctors when considering dialysis.

Why dialysis?

The kidneys’ primary role is to remove waste and extra fluid from the blood. Chronic kidney disease occurs when kidneys gradually lose their ability to function. As the disease advances, serious complications can occur, such as bone disease, nerve damage, anemia, stroke, or heart attack. When kidney disease reaches an advanced stage, known as end-stage renal disease or stage 5, doctors may recommend dialysis.

There are several types of dialysis, but most adults over age 75 receive hemodialysis, in which waste and water are filtered out of the blood via a machine. Typically, hemodialysis requires three sessions a week at a hospital or a dialysis center. Each session takes between three and five hours, in addition to travel time. Patients often feel extremely fatigued after dialysis—which some people describe as feeling “washed out”—and spend the remainder of the day resting.

A commentary published in February 2019 in the American Journal of Kidney Diseases identifies the harms associated with dialysis in older adults, which include:

  • Multiple surgeries to create access for catheters
  • Mental and physical decline
  • An increase in hospitalizations
  • The likelihood of dying in a hospital instead of at home or in hospice
  • An increased risk of a sudden stroke or a heart attack
  • A high risk of death during the first three months of therapy

Dialysis can cause low blood pressure; dry, itchy skin; abdominal cramps; headaches; shortness of breath; and sleep disorders.

Conservative management vs. dialysis

Dialysis—or a kidney transplant—is typically recommended for otherwise healthy older adults who are expected to survive for more than three years. Dialysis may not significantly extend life or lead to any meaningful benefit for frail, elderly patients ages 75 and older who have:

  • Multiple other chronic conditions
  • Physical or mental impairments that affect function
  • Severe malnutrition
  • A poor prognosis because of other medical problems

In a review published in 2017 in the journal Nephron, researchers analyzed 12 studies that included 11,515 patients with end-stage kidney disease. Dialysis in elderly patients with end-stage kidney disease resulted in an average survival time of eight to 67 months compared with six to 30 months for patients who chose conservative management.

However, the survival advantage for dialysis tends to diminish significantly with advanced age or the presence of other serious health conditions such as diabetes, heart disease, liver disease, or vascular disease, according to a 2017 Austrian study published in PLoS ONE. Such older adults who don’t want the burden of dialysis and prefer that their care focus on meaningful quality of life should be offered what’s known as “conservative management” instead of dialysis.

Conservative management of chronic kidney disease focuses on relieving symptoms and maintaining the best possible quality of life without dialysis. You and your health care team should together discuss your priorities and goals and the benefits and burdens of treatment strategies. The National Institute of Diabetes and Digestive and Kidney Diseases suggests asking your doctor the following questions when deciding between dialysis and conservative management:

  • Will dialysis improve my quality of life?
  • Will dialysis prolong my life?
  • Is there any downside to trying dialysis first?
  • What should I do to prepare for conservative management?
  • Who will continue to provide my care?
  • Will I be in pain?
  • Can I stay at home?

If you don’t choose dialysis

If you decide not to pursue dialysis and choose conservative management, your health care team should work with you to minimize the disease’s progression; optimize your kidney function; and manage any pain, other conditions, and symptoms, including depression and anxiety.

Your doctors will prescribe drugs as needed to maximize your quality of life. Toward the end of your life, you may receive care from hospice, which offers symptom relief and physical, emotional, and social support in your home or a care facility.

This article first appeared in UC Berkeley Health After 50.

Also see Kidney Stones on the Rise.