Updated 7/6/12
As pressures to control medical costs intensify, more light will be shed on the clinical reality of overdiagnosis and overtreatment, which I have recently discussed. With modern medicine falsely suggesting that death is optional, we continue to expand the indications for expensive procedures.
Hemodialysis (HD) is one of these procedures. The rate at which it is administered has increased rapidly in recent decades, and individuals at least aged 65 years are the largest driver of utilization. Additional pressures to increase HD use arise from data suggesting improved outcomes if started in patients with higher glomerular filtration rates and if it is conducted more frequently.
But among the elderly with chronic kidney disease (CKD), no significant changes in the one-year dialysis survival rate have been observed over the past several decades. Ninety-day mortality is almost 33% among individuals older than 84 years and almost half have died by one year. Functional decline accelerates and the burden of treatment increases precipitously after HD initiation. A minority of patients (13%) maintain pre-dialysis levels of functioning at 12 months. Six months after starting dialysis, patients report more symptoms; only half report HD to be an acceptable treatment. Perceived survival “benefits” are frequently spent in the hospital or in the dialysis unit. Are we really serving the best interests of our patients? If not, what is the alternative?
Dr. Bjorg Thorsteinsdottir and colleagues from the Mayo Clinic challenge us to consider palliative care strategies instead of, or in conjunction with, HD for our elderly patients (Mayo Clinic Proceedings 2012;87:514-6). The group reports that patients are comfortable discussing end-of-life issues with the nephrology and primary care teams. The vast majority (97%) prefer detailed survival information before consenting to HD. Shared decision-making tools have been developed that may facilitate this process with patients and their families.
Palliative medicine programs need to be expanded for elderly patients in our nephrology training and clinical programs. We need to get beyond the mentality that these decisions are driven by limited resources. Informed, evidence-based, patient-centered decisions about HD incorporating discussions about palliative care are truly the best medicine for our elderly with CKD.
Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, MN. He declares having no conflicts of interest. The opinions expressed are solely those of the author. Contact him at ebbert.jon@mayo.edu.
Update: A citation and a link to Dr. Bjorg Thorsteinsdottir's study was added to this blog entry.