Providing choice for patients facing kidney failure

July 21, 2020

A New England Journal of Medicine editorial by UCI Health physicians highlights the need for clinicians to fully present opportunities and ethical choices to patients who face end-stage renal failure. The editorial, “Ensuring choice for people with kidney failure — dialysis, supportive care, and hope,” by Kamyar Kalantar-Zadeh, MD, MPH, PhD, and Solomon Liao, MD, of the University of California, Irvine, and Aaron Wightman, MD, of the University of Washington, was published online this month.

More than 40 years ago, the United States committed itself to ensuring that those suffering from chronic kidney disease and end-stage renal failure have access to life-sustaining dialysis treatment. Kalantar and Liao note that recent evolutions in healthcare policy, including the Affordable Care Act’s financial incentives to reduce hospital lengths of stay and readmissions and a 2019 presidential executive order intended, in part, to promote home dialysis as an alternative to hospital- and clinic-based care, have changed the way many clinicians discuss kidney failure decisions patients face.

“I worry that dialysis patients will become a lower priority,” said Kalantar, a UCI Health nephrologist and chief of the Division of Nephrology, Hypertension & Kidney Transplantation in the UCI School of Medicine. “We need to make sure that some of these perverse incentives and other important goals do not cause a conflict of interest to compromise patient choice. Patients should not feel forced to stop dialysis, in the same way that patients shouldn’t feel pressured to start dialysis.”

Dialysis treatment prolongs life, but it can also bring physical, psychosocial and financial impacts that may be burdensome for patients and their care partners, the editorial notes. Patients starting dialysis will live an average of less than 5 years more.

Liao, director of palliative care at UCI Medical Center, said dialysis, especially as pursued in traditional models such as hemodialysis therapy three times per week in an outpatient dialysis clinic, may not be the right choice for some elderly and frail patients with multiple medical morbidities, and who may not live much longer even with dialysis.

The authors outline the following options for maximizing choice opportunities:

  • Conservative and preservative management of chronic kidney disease to delay dialysis initiation, including use of diet and lifestyle modifications, conventional and new pharmacotherapies, and pro- active management of symptoms such as pain and fatigue, as well as mental health issues;
  • Making a gradual transition to dialysis, perhaps initiating once-to-twice weekly hemodialysis or less-than-daily peritoneal dialysis at home;
  • Expanded use of palliative care in outpatient and inpatient settings to manage symptoms and review treatment options;
  • Offering palliative dialysis with a gradual decrease in frequency and intensity so that patients and care- givers can choose less-stringent dialysis therapy with a goal of improving comfort.

“Despite its flaws and burdens, dialysis prolongs life for many people — people who choose to start or continue this therapy to maintain hope in the face of organ failure,” Kalantar and Liao wrote. “Although patients may ultimately choose to avoid dialysis or withdraw from treatment, decisions to initiate or continue it should also be respected and protected. We call for increased support for collaborative efforts and amended policies so that patients may have a better range of options for their care; enjoy improved quality of life, including better management of pain and other symptoms; and have their goals supported and realized.”

The rising incidence of chronic kidney disease and end-stage kidney failure constitutes a public health emergency, driven by increasing rates of diabetes and obesity. Each year in the US, approximately 120,000 people with kidney failure choose to start dialysis therapy — an arduous, life-sustaining treatment — and more than half a million patients already receiving dialysis continue their treatment.

UCI Health is the clinical enterprise of the University of California, Irvine. Patients can access UCI Health at primary and specialty care offices across Orange County and at its main campus, UCI Medical Center in Orange, California. The 418-bed acute care hospital, listed among America’s Best Hospitals by U.S. News & World Report for the 20th consecutive year, provides tertiary and quaternary care, ambulatory and specialty medical clinics, and behavioral health and rehabilitation services. UCI Medical Center is home to Orange County’s only National Cancer Institute-designated comprehensive cancer center, high-risk perinatal/neonatal program and American College of Surgeons-verified Level I adult and Level II pediatric trauma center and regional burn center. UCI Health serves a region of nearly 4 million people in Orange County, western Riverside County and southeast Los Angeles County. Follow us on Facebook and Twitter.

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