Nephrology Hypertension

Hemodialysis: Withdrawing from Dialysis and the Role of Palliative Care

Does this patient have a poor prognosis?

Answer the "Surprise Question". "Would you be surprised if the patient dies within the next 6 months?

Generally these will be patients over 75 years of age with at least one comorbidity .

What tests to perform?

  • The simplest test is to answer the "Surprise Question."

  • A more accurate mortality tool is found at http://touchcalc.com/calculators/sq; this is also available as an smart phone app Qx Calculate.

  • Simple scoring tools were published by Couchoud (2008) and Mauri (2008).

  • If the answer to the Surprise Question in "no" you would not be surprised, and/or the predicted mortality is < 6 months you should consider withdrawal of dialysis or withholding dialysis if the patient has not started yet. This should be accompanied by "Supportive" or Palliative care.

How should patients with a poor prognosis be managed?

  • Discuss prognosis in a sensitive and compassionate way with the patient and family. The following communication techniques are helpful in breaking bad news: SPIKES and NURSE

  • Get help from palliative care and geriatric consultants and refer to hospice

  • Have patient complete Advanced Care Plan such as "Five Wishes" and "Caring Conversations"

  • In the United States those states that have The Physicians Orders for Life Sustaining Treatment Paradigm (POLST), complete the POLST with the patient and family.

  • Discontinue treatments that do not contribute to patient comfort; non comfort meds, IVs, tube feedings.

  • Treat troublesome symptoms, especially pain, use renal appropriate meds and doses to avoid neurotoxicity (ie, no Demerol)

What happens to patients with a poor prognosis?

  • Patients who stop dialysis with little residual renal function die within 8 days median time period. If a patient has is stage 5 chronic kidney disease (CKD) and has not started dialysis they may never become uremic and may live months or years.

    • Patients aged 75 or older have a very slow progression of CKD and are much more likely to die rather than reach end-stage renal disease (ESRD) (dialysis). Early start to dialysis has not been show to be beneficial.

    • "Conservative Management" (ie, no dialysis) programs in the United Kingdom have shown similar survival to dialysis in CKD 5 patients older than 75 with intermittent hemodialysis (IHD) or 2 comorbidities.

    • Make sure to adjust doses of medication for renal failure and avoid drugs that have neurotoxic metabolites (morphine)

How to utilize team care?

  • Palliative care consultant

  • Hospice referral

  • Clergy

  • Geriatrics Consultant

Are there clinical practice guidelines to inform decision making?

  • Renal Physician's Association's (RPA's) 2010 Clinical Practice Guideline Shared Decision Making: The Withholding and Withdrawal from Dialysis

  • Evidence is limited in this area with few randomized controlled trials (RCTs)

Other considerations

  • Patients who stop dialysis with little residual renal function die within 8 days.

What is the evidence?

Cohen, LM, Ruthazer, R, Moss, AH, Germain, MJ. "Predicting six-month mortality for patients who are on maintenance hemodialysis". Clin J Am Soc Nephrol.. vol. 5. 2010. pp. 72-79.

(Integrated mortality predictor for dialysis patients. Available on line and for smart phones.)

Rosansky, SJ, Eggers, P, Jackson, K, Glassock, RJ, Clark, WF. "Early start of hemodialysis may be harmful". Arch Int Med. 2010.

(This editorial suggests that elderly patients may not benefit and in fact may be harmed by early start of dialysis.)

Chambers, E, Brown, E, Germain, M. "Supportive Care for the Renal Patient". Oxford University Press. 2010.

(This is the only textbook of palliative care for renal disease.)

Cooper, BA, Branley, P, Bulfone, L. "A randomized controlled trial of early versus late initiation of dialysis". N Engl J Med.. vol. 363. 2010. pp. 609-619.

(This RCT did not show a benefit from an early start of dialysis.)

Kurella Tamura, M, Covinsky, KE, Chertow, GM, Yaffe, K, Landefeld, CS, McCulloch, CE. "Functional status of elderly adults before and after initiation of dialysis". N Engl J Med. vol. 361. 2009. pp. 1539-1547.

(This study demonstrates extremely poor outcome for nursing home patients who start dialysis.)

Thakar, CV, Quate-Operacz, M, Leonard, AC, Eckman, MH. "Outcomes of hemodialysis patients in a long-term care hospital setting: a single-center study". Am J Kidney Dis. vol. 55. 2010. pp. 300-306.

(This study found poor outcome in longterm care hospital patients on dialysis.)

"Shared Decision-Making in the Appropriate Initiation and Withdrawal From Dialysis Clinical Practice Guidelines". RPA. 2010.

(Second edition of the only national evidenced based guidleline on palliative care for kidney patients.)

Citko, J, Moss, A, Carley, M, Tolle, S. "The National POLST Paradigm Initiative". Fast Fact and Concepts. vol. 178. September 2010. http://www.eperc.mcw.edu/fastfact/ff_178.htm.

(Physician Orders for Life Sustaining Treatments is legal now in over 20 states and spreading across the country. It is hoped this will improve ACP which has been very disappointing.)

Moss, AH, Ganjoo, J, Sharma, S. "Utility of the “surprise” question to identify dialysis patients with high mortality". Clin J Am Soc Nephrol. vol. 3. 2008. pp. 1379-1384.

(The simple question "Would I be surprised if this patient dies in the next 1 year" is a powerful predictor of mortality in dialysis patients.)

Chandna, SM, Da Silva-Gane, M, Marshall, C, Warwicker, P, Greenwood, RN, Farrington, K. "Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy". Nephrol Dial Transplant Advance.

(One of a number of studies that show the clinical utility of "conservative" (non-dialysis) management of advanced CKD in the elderly.)

Carson, RC, Juszczak, M, Davenport, A, Burns, A. "Is maximumconservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease?". Clin J Am Soc Nephrol.. vol. 4. 2009. pp. 1611-1619.

In this study of conservatively managed patients any days of life gained were spent in the hospital or dialysis.

Murtagh, FE, Marsh, JE, Donohoe, P, Ekbal, NJ, Sheerin, NS, Harris, FE. "Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5". Nephrol Dial Transplant. vol. 22. 2007. pp. 1955-1962.

(Conservatively managed patients over 75 with > one comorbidity or IHD survived as long as patients who chose dialysis.)

Marinovich, S, Lavorato, C, Morinigo, C. "A new prognostic index for one-year survival in incident hemodialysis patients". Int J Artif Organs. vol. 33. 2010. pp. 689-699.

(One of a number of mortality predictors.)

Kurella Tamura, M, O'Hare, AM, McCullock, CE, Johansen, KL. "Signs and symptoms associated with earlier dialysis initiation in nursing home residents". Am J Kidney Dis. vol. 56. 2010. pp. 1117-1126.

(n 2/3 of nursing home patients who start dialysis, an early start to dialysis is not associated with medical factors such as volume overload, congnitive or functional decline.)

O'Hare, AM. "The management of older adults with a low eGFR: moving toward an individualized approach". Am J Kidney Dis. vol. 53. 2009. pp. 925-927.

(An editoral that provides a practical and thoughtful approach to discussing dialysis in the elderly patient.)

Montse, C, Emii, V. "Design and validation of a model to predict early mortality in haemodialysis patients". Nephrol Dial Traansplant. vol. 23. 2008. pp. 1890-1696.

Couchoud, C, Labeeuw, M, Moranne, O, Allot, V, Esnault, V, Frimat, L, Stengel, B. "A clinical score to predict 6-month prognosis in elderly patients starting dialysis for end-stage renal disease". Nephrol Dial Transplant. vol. 24. pp. 1553-1561.

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