Slow Medicine: Force-Feeding Dialysis

How often does a reluctant patient with advanced kidney disease agree to start dialysis at the behest of her doctors? We've seen it many times, and apparently we're not alone.

A new analysis in JAMA Internal Medicine found that whether or not a patient begins dialysis has more to do with physician style, chance, and community standards than with objective clinical measures or patient preferences.

The researchers individually reviewed records from more than 1,600 patients at the VA who initiated dialysis between 2000 and 2009. They concluded that a decision to initiate dialysis was primarily determined by:

• The physician's style, i.e., certain physicians seemed to promote early dialysis initiation more than others
• An acute clinical event, such as a hospitalization, in which the "imperative to treat often seemed to override patient choice"
• Patient-physician discussions. The researchers note that these discussions "were sometimes adversarial, and physician recommendations to initiate dialysis sometimes seemed to conflict with patient priorities"

These findings are especially noteworthy in light of recent data suggesting that earlier dialysis initiation does not improve outcomes.

Most notably, in 2010 the IDEAL trial compared outcomes among more than 800 patients with stage 5 chronic kidney disease who were randomized to either start dialysis once the glomerular filtration rate (GRF) dropped below 15 ml per minute or to a conservative strategy of waiting for a traditional indication for dialysis (i.e., unmanageable electrolyte disturbances, volume overload, or symptoms of uremia).

The trial demonstrated that not only was GFR-based initiation no better than the conservative strategy with respect to mortality, cardiovascular events, and fluid and electrolyte complications, but that the conservative strategy enabled patients to remain off dialysis for an average of six additional months – limiting burdens on patients and reducing wasteful spending.

Even as new research raises questions about the benefits of early dialysis, evidence suggests that nephrologists are starting dialysis at earlier and earlier stages. It is likely that numerous factors – financial and otherwise – have driven this trend.

One such factor has been a push for earlier referral to nephrologists among patients with chronic kidney disease. While we do support referral to nephrologists for most younger patients with stage 4 chronic kidney disease (GFR 15-30 mL per minute) who are at high risk of ultimately requiring dialysis – a practice that helps prepare these patient for dialysis and has been associated with improved outcomes – this does not mean these patients should actually initiate dialysis until it is clearly necessary.

Moreover, in certain patients -- frail elderly patients or those with limited life expectancies -- nephrology referral for stage 4 disease often does not make sense. Many such patients may not end up requiring dialysis due to their limited life expectancy, and evidence suggests that frail elderly experience little benefit from the procedure. In our experience, early nephrology referral among such patients often just leads to uncertainty and anxiety.

The decision about when – or if -- someone with advanced kidney disease should embark on dialysis is complex. For some, dialysis can serve as a bridge to transplant or may offer an opportunity to meaningfully extend life; for others, it may simply prolong suffering. Such a situation calls for careful consideration of an individual patient's goals and values. The fact that so frequently dialysis initiation is affected by physician-centric rather than patient-centric factors is cause for great concern.

"Updates in Slow Medicine" applies the latest medical research to support a thoughtful approach to clinical care. It is produced by Pieter Cohen, MD, of Harvard Medical School, and Michael Hochman, MD, of AltaMed Health System in Los Angeles. Rachael Bedard, MD, is a palliative care fellow at the Mount Sinai Hospital in New York. To learn more, visit their Facebook page.

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Slow Medicine: Force-Feeding Dialysis