Dialysis machine

Older, frail patients with kidney failure may benefit from a new approach to dialysis discussions that supports a deferred decision, according to a new perspective in the Journal of the American Society of Nephrology

Dialysis is a lifesaver for many patients with end-stage renal disease. But in many cases it becomes a default clinical prescription that may not always be supported by the evidence for older and frail patients, according to nephrologist and palliative care specialist Fahad Saeed, M.D., of the University of Rochester Medical Center, and colleagues.

More than half of patients aged 65 years and older die within 12 months of initiating dialysis, the authors reported. In addition, older patients with chronic kidney disease have been found to prefer a focus on living well in the present, rather than planning for the future. Other studies have found that these patients don’t believe that they have a choice — or that they may feel pressured into agreeing to dialysis, the authors wrote.

“Deciding not to decide”

The authors propose that, along with the usual options — transplantation, home or in-center dialysis and active medical management without dialysis — physicians should add a new option they call “deciding not to decide” (DND).

Although shared decision-making between physicians and older patients with kidney failure was formerly recommended by the American Society of Nephrology’s Choosing Wisely Campaign a decade ago, “genuine shared decision-making is rarely incorporated” into these discussions, the authors wrote.

“Both patients and nephrologists report being emotionally burdened by renal replacement therapy [RRT or dialysis] decision-making,” they wrote. “Many patients are ambivalent about their RRT choices, and want more time to finalize a decision. Similarly, many nephrologists feel uncomfortable not offering dialysis for reasons that are poorly understood, but may include prognostic uncertainty and discomfort with death.”

Shared decision-making upgrade

The DND option “intentionally defers the decision and lets patients revisit RRT choices at a mutually agreeable time,” helping to better foster shared decision making and patient autonomy, among other positive outcomes, they explained.

The authors present a framework for the DND option that includes recommendations on how to counsel the patient and family members. If a patient chooses the DND approach, the choice would then be documented in the patient’s chart, the authors said. Quality of life is then “maintained or enhanced by either their primary clinician, or a palliative care specialist,” they explained.

The DND approach has advantages and disadvantages, the authors acknowledge. But they argue that it warrants careful consideration, and expect that it will be welcomed by older patients who are not yet ready to commit to any treatment option.

“It does not force patients to choose a particular RRT modality before they have been informed of all of the options, nor does it subject them to dialysis access procedures in advance of their readiness to settle on a particular treatment option,” they concluded.