Rebecca J. Schmidt, DO, FACP, FASN
Professor of Medicine and Chief, Section of Nephrology
West Virginia University School of Medicine
WVU Healthcare
June 29, 2012
Introduction and Background
 Fastest growing sector of incident ESRD are older patients
 Estimated that 47% of individuals > 70 have CKD
 Proportion > 65 starting dialysis has increased ~10%/yr
 Overall increase of 57% between 1996 and 2003
 Elderly (> 75) have high prevalence of comorbid conditions
 Clinical guidelines are not age-specific
 Pathophysiology and natural history of CKD in the elderly
differs from that of younger patients
 Armamentarium of tools for patient education evolving
Learning Objectives
 To understand the rationale for taking an age-attuned
approach when providing informed consent to older
patients with chronic kidney disease (CKD).
 To recognize the characteristics that signify a poor
prognosis in the older CKD patient.
 To be prepared to address specific issues in informed
consent discussions with older CKD patients.
Outline
 Options and ethical issues
 Likelihood of renal disease progression before death
 Impact of age, functional status, comorbid conditions
and dialysis on survival
 Burdens of dialysis and risk to quality of life
 Informing prospective dialysis patients about the
contingencies of their consent
 Specific issues to address in informed consent
discussions with older patients
Case Presentation
A 78 year old white female was referred for CKD care with an
eGFR of 39 ml/min/1.73m2 and anemia. She also had DM, HTN,
CAD, ICM, HLD, MDS and PVOD. Her renal function remained
stable for the next 7 months, after which the patient missed all
CKD clinic appointments until referred back again by her PCP 2
years later, having sustained 2 additional myocardial infarctions
requiring placement of 5 coronary artery stents. Her eGFR was
now 30 ml/min/1.73m2, and she was advised that hemodialysis
might be difficult consequent to cardiac disease and other
comorbid conditions. As her GFR fell to 15 ml/min/1.73m2, the
patient decided to pursue dialysis because she wanted "to live for
my family.” Her family was supportive of this stance, stating "we
have to do everything we can.”
Options and Ethical Issues/Questions
 Renal replacement therapy options
 Patient preferences, competence, and understanding
 Expectations regarding quantity and quality of life
 Contextual issues
 What is “everything?’
 Does opportunity command obligation?
Options
 Renal Replacement Therapy
 Hemodialysis
 Peritoneal dialysis
 Home dialysis
 Transplantation
 No Renal Replacement Therapy
Opportunity and Choice
Legislation
assuring
coverage of
dialysis
(1972)
Increased
effectiveness
of RRTx
Decreased
risks of RRTx
Incorporation
into standard
practice
Effective
elimination
of choice
Ethical Responsibility to Do No Harm
Opportunity to
extend life
Obligation to
extend life
Typical Illness Trajectories For Chronic Illness
Murray S A et al. BMJ 2005;330:1007-1011
Trajectories of Illness
Holley J L CJASN 2012;7:1033-1038
©2012 by American Society of Nephrology
Trajectory of
Illness for ESRD
Trajectory of
Functional Decline in
the Last Year of Life
Murtagh JAGS 59:304-308, 2011
Transitioning from CKD to ESRD
Dialysis Access
CKD Status
• CKD Stage
• Knowledge
• Prognosis
• Renal
• Overall
• Signs/sx
Comorbid
Conditions
• CVD
• HTN
• Diabetes
• COPD
• Other
• Expectations
Psychosocial
Issues
• Available
expertise
• State of mind
• Logistics of
• Cognitive
scheduling,
abilities
transport
• Willingness or
• Payment
capacity to
comply
• Family
support,
influence,
involvement
Burdens of
RRTx
• Physical
• Financial
• Logistic
• Family
Patient Challenges
 Accepting and coping with chronic condition
 Accepting disruption of current life
 Finding the financial resources
 Dealing with uncontrollable consequences
 Dealing with loss of independence and control
 Accepting changes in role (family, friends, work)
 Maintaining meaning to life
 Confronting one’s own mortality
Provider Challenges
RJ Schmidt and BS Pellegrino, Guest Editors. Primary Care of the
Patient with Chronic Kidney Disease. Advances in CKD 18:6, 2011.
Expected remaining lifetimes (years) of
the U.S. population & of dialysis & transplant patients,
by age, gender, & race
Table 6.b (Volume 2)
General U.S. population, 2004
All races
White
All
M
F
All
0-14
71.4 68.8 73.9 71.8
15-19
61.6 59.1 64.1 62.0
20-24
56.9 54.4 59.2 57.2
25-29
52.1 49.7 54.4 52.5
30-34
47.4 45.1 49.5 47.7
35-39
42.7 40.4 44.7 42.9
40-44
38.0 35.8 40.0 38.3
45-49
33.5 31.4 35.4 33.7
50-54
29.2 27.2 30.9 29.3
55-59
25.0 23.1 26.5 25.1
60-64
21.0 19.3 22.4 21.0
65-69
17.2 15.7 18.5 17.3
70-74
13.8 12.5 14.8 13.8
75-79
10.8
9.7 11.5 10.7
80-84
8.2
7.3
8.7
8.1
85+
4.4
3.9
4.6
4.3
Overall 25.2 23.4 26.6 25.3
USRDS 2009
M
69.2
59.5
54.8
50.1
45.4
40.7
36.1
31.7
27.4
23.3
19.4
15.8
12.5
9.6
7.2
3.8
23.6
ESRD patients, 2007
African American Dialysis
Transplant
F
All
M
F
All
M
F
All
M
74.3 67.2 63.7 70.3 19.8
20.5 19.1 55.0 54.7
64.4 57.5 54.0 60.6 17.6
18.5 16.6 42.4 42.0
59.5 52.7 49.4 55.7 14.9
15.8 13.9 38.4 38.0
54.7 48.1 44.9 50.9 13.2
13.9 12.3 35.1 34.7
49.8 43.5 40.5 46.2 11.4
11.8 10.8 31.3 30.8
45.0 39.0 36.0 41.5
9.9
10.3
9.5 27.8 27.2
40.2 34.5 31.6 37.0
8.6
8.8
8.4 24.3 23.7
35.6 30.3 27.5 32.6
7.4
7.5
7.3 21.1 20.5
31.1 26.3 23.7 28.5
6.5
6.6
6.4 18.1 17.4
26.6 22.6 20.1 24.5
5.6
5.7
5.6 15.5 14.8
22.4 19.1 16.9 20.7
4.8
4.8
4.9 13.1 12.4
18.5 15.9 14.0 17.2
4.1
4.0
4.1 10.8 10.2
14.8 13.0 11.4 14.0
3.4
3.4
3.5
8.9
8.4
11.5 10.4
9.1 11.2
2.9
2.8
2.9
7.5
7.0
8.6
8.3
7.3
8.7
2.4
2.3
2.5
4.5
5.0
4.4
5.1
1.9
1.9
2.0
26.7 23.1 20.9 24.8
5.9
6.0
5.9 16.4 15.8
F
55.6
43.0
39.1
35.9
32.2
U.S. data: calculated from
28.8
Tables 1–9 in the United States
25.4 life tables (Arias E). Available at
22.3 http://www.cdc.gov/nchs/dat
19.3 a/nvsr/nvsr56/nvsr56_09.pdf.
ESRD data: prevalent dialysis &
16.7 transplant patients, 2007.
14.2 Expected remaining lifetimes
11.8 by race & gender can be found
in Reference Table H.31.
9.8
Prevalent ESRD population,
8.3 2007, used as weight used to
calculate overall combined-age
remaining lifetimes.
17.4
Predictors of mortality in Medicare patients age 66 & older, by
age, gender, race, at-risk group, & comorbidity
Table 5.b (Volume 1)
66–69
70–74
75–84
85+
Male
Female
White
African American
Other
No CKD, DM, or CVD
CKD (NDM, non-CVD)
DM (non-CKD, non CVD)
CVD (non-CKD, non-DM)
CKD+DM
CKD+CVD
DM+CVD
CKD+DM+CVD
Hypertension
Liver disease
GI disease
Cancer
COPD
Anemia
USRDS 2009
2003
RR
1
1.33
2.34
6.30
1.16
1.00
1.00
1.13
0.87
1.00
1.99
1.23
1.84
2.10
3.10
2.45
4.07
0.81
1.70
1.24
1.86
1.98
1.70
CI
1.29 - 1.38
2.28 - 2.42
6.11 - 6.49
1.14 - 1.17
1.1 - 1.16
0.83 - 0.9
1.83 - 2.17
1.19 - 1.28
1.8 - 1.88
1.86 - 2.37
2.98 - 3.22
2.39 - 2.51
3.91 - 4.24
0.8 - 0.82
1.6 - 1.81
1.21 - 1.28
1.83 - 1.9
1.94 - 2.01
1.67 - 1.73
2005
RR
1
1.34
2.38
6.43
1.14
1.00
1.00
1.16
0.82
1.00
1.60
1.22
1.81
2.05
2.85
2.36
3.57
0.81
1.79
1.26
1.84
1.96
1.71
CI
1.29 - 1.38
2.31 - 2.46
6.24 - 6.62
1.12 - 1.15
1.13 - 1.19
0.79 - 0.86
1.47 - 1.74
1.18 - 1.27
1.78 - 1.85
1.84 - 2.28
2.74 - 2.96
2.3 - 2.42
3.43 - 3.71
0.8 - 0.83
1.69 - 1.9
1.22 - 1.3
1.8 - 1.87
1.93 - 1.99
1.68 - 1.74
2007
RR
1
1.35
2.38
6.34
1.13
1.00
1.00
1.15
0.85
1.00
1.72
1.12
1.80
1.80
2.77
2.19
3.35
0.81
1.84
1.25
1.80
1.95
1.72
CI
1.3 - 1.4
2.31 - 2.46
6.15 - 6.55
1.11 - 1.15
1.12 - 1.18
0.82 - 0.89
1.6 - 1.85
1.08 - 1.16
1.76 - 1.83
1.63 - 1.98
2.67 - 2.86
2.13 - 2.25
3.23 - 3.47
0.8 - 0.83
1.73 - 1.95
1.21 - 1.29
1.76 - 1.83
1.92 - 1.99
1.69 - 1.75
Point prevalent on January 1
of each year, age 66 & older.
Comorbidities identified
from claims in prior year,
and exclude patients
enrolled an HMO, with
Medicare as secondary
payor, or diagnosed with
ESRD in the prior year
Followed from January 1 to
December 31 of the year,
censored at ESRD date and
the end of Medicare
entitlement. Results are
from multivariable Cox
regressions.
Relative Survival by Illness
Nordio et al. American Journal of Kidney Diseases 2012; 59:819-828 (DOI:10.1053/j.ajkd.2011.12.023 )
Unadjusted & Adjusted All-Cause Mortality Rates
in Medicare CKD & Non-CKD Patients, by Age
Figure 4.16 (Volume 1)
Point prevalent Medicare patients age 66 & older. Adj: gender/race/hospitalization/comorbidity; ref: 2005 cohort.
Likelihood of Renal Disease Progression
before Death
Cumulative
incidence of
end-stage renal
disease (ESRD),
cardiovascular
death, and noncardiovascular
death during
follow-up
Dalrympal. J Gen Intern Med 26(4):379-85, 2010.
Age and Survival in CKD 4
(A) Proportion of patients surviving by age group at referral. Curves are generated from the Cox
regression equation and are adjusted for baseline haemoglobin, eGFR and diastolic blood
pressure and early rate of change in renal function.
Conway et al. Nephrol. Dial. Transplant. 2009;24:1930-1937
Age and Progression to ESRD
(B) Cumulative risk of likelihood of renal replacement therapy by age at referral. Curves are generated
from the failure function of the Cox regression equation and are adjusted for early rate of change in
eGFR and level of proteinuria, haemoglobin and eGFR at referral.
Conway et al. Nephrol. Dial. Transplant. 2009;24:1930-1937
Likelihood of Renal Disease Progression
before Death
 GFR of <30
 Progressive, irreversible deterioration in kidney
function over reasonable period of observation
 Presence of diabetes
 Presence of proteinuria
O’Hare. Kidney Int 71:555-561, 2007
O’Hare. J Am Soc Nephrol 18:2758-2765, 2007
Eriksen. Kidney Int 69:375-382, 2006
Hall. Clin J Am Soc Nephrol 5:828-835, 2010
Evans. Am J Kidney Dis 46:863-870, 2005
Stevens. Am J Kidney Dis 55:S23-S33, 2010
Hemmelgarn. Kidney Int 69:2155-2161, 2006.
Indicators of Poor Prognosis
 Marked functional impairment
 Frailty
 History of falls
 Inability to transfer
 Serum albumin below 3.5 gm/dl
 Yes to the surprise question
 High Charlson Comorbidity Scores
Frailty is Important
 General population:
 Frailty criteria met by 7% > 65 and 40% >80 years
Fried. J Gerontol A Biol Sci Med Sci. 56:M146-M156, 2001
 Elderly CKD patients:
 Frailty with CKD is increased 2-F and 6-F if GFR < 45 (even
corrected for comorbid)
 Frailty + CKD = increased death
Wilhelm. Am J Med. 122:664-671, e2, 2009
 Elderly ESRD patients:
 74% in 60-70 age group; 79% in over 80 age group
 Risks of death 2.24 and hospitalization 1.56 for frail pts
Johansen. J Am Soc Nephrol .18:2960-2967
Loss of Independence in Elderly Patients
After Starting Dialysis
Living Status and Residence during the Study Period, Assessed at 6-Month Intervals.
Jassal SV et al. N Engl J Med 2009;361:1612-1613.
Functional Status in Elderly Patients After
Starting Dialysis
Change in Functional Status after Initiation of Dialysis.
Kurella Tamura M et al. N Engl J Med 2009;361:1539-1547.
Malnutrition Linked to Mortality in
Dialysis Patients
 Undernourished, small (low BMI) with low albumin and
BUN levels have poorest survival
 Albumin <4 g/dl single lab finding of import
 Decrease in albumin is dose-dependent
 OR 1.48 for albumin 3.5-3.9; 3.13 for albumin 3.0-3.4
 Does not prove cause and effect
 Meaning of hypoalbuminemia may differ among HD vs.
PD patients but malnutrition by SGA and initial fat-free
body mass independently predicts death
Chung 2000
Owen 1993
Lowrie 1990
Goldwasser 1994
Keshiaviah 1994
Surprise Question
Would I be surprised if this patient died in the next year?
Moss, Clin J Am Soc Nephrol 3:1379-1384, 2008
Characteristics Signifying a Poor Prognosis
 High comorbidity scores (e.g., modified Charlson Comorbidity
Index score of ≥ 8)
 Marked functional impairment (e.g., Karnofsky Performance
Status Scale Score < 40)
 Frailty
 History of falls
 Inability to transfer
 Severe chronic malnutrition (e.g., serum albumin level < 2.5
g/dL using the bromcresol green method)
 Nephrologist would not be surprised at their death
RPA Clinical Practice Guideline in the Appropriate Initiation and Withdrawal from
Dialysis, 2nd Edition, 2010.
Johansen. J Am Soc Nephrol 18:2960-2970, 2007.
Arnold. N Engl J Med 361: 1597-1598, 2009.
Case Presentation - continued
She was not keen on peritoneal dialysis, so an AVF was placed and
the patient was followed in the CKD Clinic awaiting the
appropriate time to start dialysis. When she had her fifth heart
attack and another PTA, signs of pulmonary edema prompted the
decision to start dialysis; however, the AVF was poorly functional
and she ultimately required placement of a TCC to achieve
meaningful dialysis. The TCC required several replacements for
which she traveled the 4-hour round trip to the hospital for this
procedure and on several occasions underwent an urgent dialysis
treatment for volume overload by virtue of a missed treatment
because of no access. Revision and/or recreation of vascular
access were deferred for 6 months for cardiac reasons and 5
months later, she was admitted for GI bleeding, developed chest
pain and underwent additional coronary artery PTA and stents.
Impact of Dialysis on Survival
 Survival benefit for selected sicker patients choosing
dialysis over palliative care is small
 And not uniform
Couchoud 2009, Carson 2009, Murtagh 2007, Joy 2003, Brunori 2008, Elam 2009
 No survival benefit to dialysis in the sickest
 Better survival with dialysis unless CVDz or comorbidities
 More of those on dialysis died while hospitalized (65%) than
those choosing no dialysis (27%).
Smith. Clin Nephron Practice 2003
Murtagh. Nephrol Dial Transplant 2007
Dialysis May Not Mean Greater Survival
in Older Patients with Poor Prognosis
Kaplan-Meier survival curves for those with high comorbidity (score=2), comparing
5 dialysis and conservative groups (log rank statistics <0.001, df 1, P=0.98.
Murtagh. Nephrol Dial Transplant. 2007; 22(7):1955-62
Dialysis
May Not
Mean
Greater
Survival in
Older
Patients
with Poor
Prognosis
Impact of Age, Clinical Status and Dialysis
on Survival
 Older age and co-morbid conditions are key prognostic
indicators.
 Likelihood of progression to ESRD prior to death is an
important consideration.
 Dialysis may not confer a survival benefit over active nondialytic management in patients with a poor prognosis.
Smith. Nephron Clinical Practice 95:C40-c46, 2003.
Carson. Clin J Am Soc Nephrol 4: 1611-1619, 2009.
Wong. Ren Fail 29:653-659, 2007.
O’Hare. J Am Soc Nephrol 18:2758-2765, 2007.
Conway. Nephrol Dial Transplant 24:1930-1937, 2009.
Ellam. J Med 102:547-554. 2009.
Murtagh. Nephrol Dial Transplant 22: 1955-1962, 2007.
Chandna. Nephrol Dial Transplant 26:1608-1614, 2011
Case Presentation - continued
Further vascular access surgery was again delayed until
several months later when, with the blessing of her
cardiologist, the patient was approached about AVF
placement, but was dissuaded by her children, who were
convinced that her previous heart attack had been
precipitated by the vascular access surgery and did not
wish her to spend any more time traveling to the hospital
100 miles distant. She continued to live in her home but
required increasing support from her family for ADLs and
had little energy to enjoy even crochet despite receiving
repeated transfusions for ESA-refractory anemia.
Several months later, she suffered a cardiac arrest one
morning as she was dressing to come to dialysis.
Presents to
CKD Clinic with
eGFR 39
ml/min
Now s/p AMI x 2
and PTA x 5; many
transfusions for
MDS; eGFR 30
ml/min
May 2007-Dec 2009
After 7 months,
lost to followup
for 24 months;
eGFR still 39
ml/min
HD chosen and
AVF placed
Jan 2010-April 2010
Stable AP;
starts ESA and
Fe therapy at
CKD Clinic;
CKD options
presented
TCC replaced x 3;
AVF surgery
deferred b/o
CVDz; several
transfusions
May 2010-Dec 2010
AMI with
pulmonary
edema; ER HD
started via TCC
(AVF nonfx)
Died at home
Jan 2011-June 2011
Recurrent AP and
PTA; GI bleed;
continues with
TCC
Options
 Renal Replacement Therapy
 No Renal Replacement Therapy
 By decision
 Active non-dialytic management
Hospice and palliative care
 By default
 Emergency dialysis start
 Death

Integrated Prognostic Score
 Older age
 Dementia
 PVOD
 Low albumin
 Surprise ?
Survival across quartiles of predicted risk
Cohen L M et al. CJASN 2010;5:72-79
Prognostic Indicator Estimates at the Start
of Dialysis
Parameter
Result
Charlson Comorbidity Index
Surprise Question
Karnofsky Score
Hemodialysis Mortality Predictor
Serum albumin at dialysis start
Fistula Failure to Mature Risk
10.8 (very high)
No
50%
12 month survival - 30%
18 month survival - 12%
3.2 mg/dl (50% 1-yr mortality)
7.5 (very high)
Moss. Clin J Am Soc Nephrol. 3:1379-1384, 2008.
Cohen. Clin J Am Soc Nephro5:72-79, 2010.
Lok. J Am Soc Nephrol 17:3204-3212, 2006.
Presents to
CKD Clinic with
eGFR 39
ml/min
Now s/p AMI x 2
and PTA x 5; many
transfusions for
MDS; eGFR 30
ml/min
May 2007-Dec 2009
After 7 months,
lost to followup
for 24 months;
eGFR still 39
ml/min
HD chosen and
AVF placed
Jan 2010-April 2010
Stable AP;
starts ESA and
Fe therapy at
CKD Clinic;
CKD options
presented
TCC replaced x 3;
AVF surgery
deferred b/o
CVDz; several
transfusions
May 2010-Dec 2010
AMI with
pulmonary
edema; ER HD
started via TCC
(AVF nonfx)
Died at home
Jan 2011-June 2011
Recurrent AP and
PTA; GI bleed;
continues with
TCC
• Provide education earlier on and engage family in descriptions of options , risks and
responsibilities of dialysis for patient and family.
• Present the ‘no dialysis’ option with objectivity and enthusiasm.
• Present need for AVF, risk for FTM and prepare for AVF intervention requirements.
• Consider AVG in cases of insistence or requests for time-limited trials.
Rationale for Considering the “No
Dialysis” Option
 Survival continues to be poor for ESRD.
 Dialysis impacts quality of life on many levels.
 Life on dialysis entails burdens likely to detract
from quality of life.
 Likelihood of functional decline once starting
dialysis is high.
 Dialysis may not be the best form of therapy for
every patient.
.
Holley. Adv Chronic Kidney Dis 14:316-318, 2007.
Tamura. N Engl J Med 361:1539-1547, 2009.
Weisbord. Adv Chronic Kidney Dis 14:316-318, 2007.
When Considering the “No Dialysis” Option…
 A growing literature supports active non-dialytic
(“conservative”) management for advanced CKD.
 Active non-dialytic management may be appropriate for
certain patients with a poor prognosis for survival.
 Active non-dialytic management does not mean no
management or no care.
Smith. Nephron Clinical Practice 95:C40-c46, 2003.
Carson. Clin J Am Soc Nephrol 4: 1611-1619, 2009.
Wong. Ren Fail 29:653-659, 2007.
Advance Care Planning for Patients with CKD
 Multiple comorbid conditions, effects of chronic illness add to
the complexities of ACP for CKD patients.
 Cognitive impairment common in older CKD patients.
 Preferences about dialysis may change over time and may be
influenced by:
 Functional status
 Depression
 Cognitive ability to appreciate impact of disease on QOL
 Understanding of trappings associated with day-to-day
operations of dialysis
 Perceptions of the dying process (right or wrong) should dialysis
be foregone
Fried. J Am Geriatr Soc 55:1007-1014, 2007.
Hooper. MJA 165: 416-419. 1996.
Murray. Neurology 67:216-223, 2006.
Tools Available in the RPA Guideline for
Shared Decision Making
•
•
•
•
•
•
•
•
•
Depression Assessment
Cognitive Capacity Assessment
Decision Making Capacity Assessment
Quality of Life and Functional Status Assessment
Prognosis Assessment
National Kidney Foundation Initiation and Withdrawal Checklists
Pain and Symptom Assessment and Management
Communication Skills
Glossary of Terms
RPA Clinical Practice Guideline in the Appropriate Initiation
and Withdrawal from Dialysis, 2nd Edition, 2010.
Informed Consent for Dialysis
 Initiation of dialysis presumes appropriate provision of
informed consent
 Ideally, begins as part of ACP long before decision needed
 Importance underscored by high rates of withdrawal from
dialysis
 Second to CVD as a cause of death
 Accounts for 25% of dialysis patient deaths
 Requires sufficient understanding and knowledge of one’s
circumstances.
Informing Prospective Dialysis Patients
about the Contingencies of their Consent
 Informed consent for dialysis includes discussion of
options for permanent access.
 Requirements for permanent access warrant full
disclosure at the time of informed consent.
 Cost, pain and risk associated with surgical
intervention warrant consideration and disclosure.
Taking an Age-Attuned Approach
Specific Issues to Discuss with Older CKD Patients
 Dialysis may not confer a survival advantage over
maximum medical management.
 Patients with significant level of illness are more likely
to die than live long enough to progress to ESRD.
 Life on dialysis entails significant burdens that may
detract from their quality of life.
 It is likely that they may not experience any
functional improvement with dialysis.
El-Ghoul. JAGS 57: 2217-2223, 2009.
Tamura. N Engl J Med 361:1539-1547, 2009.
Weisbord. Adv Chronic Kidney Dis 14:316-318, 2007.
Joly. J Am Soc Nephrol 14:1012-1021, 2003.
Eriksen. Kidney Int 69:375-382, 2006.
Dalrymple. J Gen Intern Med 26:379-38, 2011.
Taking an Age-Attuned Approach
Specific Issues to Discuss with Older CKD Patients
 They may undergo significant functional decline
during the first year after dialysis initiation.
 Maximum medical management includes usual
integrated CKD care without dialysis and does NOT
mean ‘no care’.
 Palliative care is available irrespective of their
decision to pursue or forego dialysis.
 Hospice is an appropriate consideration for patients
with additional terminal illness.
RPA Clinical Practice Guideline in the Appropriate Initiation and
Withdrawal from Dialysis, 2nd Edition, 2010.
Recommendations for Providing Informed
Consent to Older Patients Contemplating Dialysis
 Initiate advanced care planning early on in the





continuum of CKD.
Integrate informed consent as part of the deliberation
process when contemplating dialysis.
Assure decision making capacity and cognitive capacity
for comprehension.
Engage the patient’s family in the decision making
process.
Present estimate of renal and overall prognosis with
and without dialysis.
Determine and agree on the patient’s goals, for both
short-term and long-term care.
Schmidt RJ. Clin J Am Soc Nephrol 7:185-191, 2012.
Recommendations for Providing Informed
Consent to Older Patients Contemplating Dialysis
 Make plans for dealing with symptoms that could occur
should renal failure progress faster than anticipated
and/or faster than other co-morbid conditions.
 Discuss desires for acute symptom management and goal
to avoid “heat of the moment” decisions.
 For those choosing dialysis, discuss modality and dialysis
access options, and explain requirements and
responsibilities associated with vascular access or
peritoneal dialysis catheter placement.
Schmidt RJ. Clin J Am Soc Nephrol 7:185-191, 2012.
Approach to the Elderly Patient with ESRD
The model uses
such factors as
cognitive
impairment,
functional
impairment,
and the
severity of
comorbid
conditions to
help guide the
clinical thought
process.
Berger J R , Hedayati S S CJASN 2012;7:1039-1046
©2012 by American Society of Nephrology
Guideline for Shared Decision
Making – 2nd Edition
Endorsed by:
Renal Physicians Association
American Academy of Hospice and Palliative Medicine
American Academy of Pediatrics
American Association of Critical Care Nurses
American Association of Kidney Patients
American College of Nurse Practitioners
American Geriatrics Society
American Society of Pediatric Nephrology
Center to Advance Palliative Care
Forum of End-Stage Renal Disease Networks
Kidney End-of-Life Coalition
National Hospice and Palliative Care Organization
National Renal Administrators Association
Society of Critical Care Medicine
Recommendations
1.
2.
3.
4.
5.
6.
Develop a physician-patient relationship for shared decision
making.
Fully inform acute kidney injury (AKI), stage 4 and 5 CKD, and ESRD
patients about their diagnosis, prognosis and all treatment
options.
Give all patients with AKI, stage 5 CKD, or ESRD an estimate of
prognosis specific to their overall condition.
Institute advanced care planning.
If appropriate, forgo (withhold initiating or withdraw ongoing)
dialysis for patients with AKI, CKD, or ESRD in certain, well-define
situations.
Consider forgoing dialysis for AKI, CKD, or ESRD patients who a
very poor prognosis or for whom dialysis cannot be provided
safely.
Recommendations, continued
Consider a time-limited trial of dialysis for patients requiring
dialysis but who have an uncertain prognosis, or for whom a
consensus cannot be reached about providing dialysis.
8. Establish a systematic due process approach for conflict
resolution if there is disagreement about what decision
should be made with regard to dialysis.
9. To improve patient-centered outcomes, offer palliative care
services and interventions to all AKI, CKD, and ESRD patients
who suffer from burdens of their disease.
10. Use a systematic approach to communicate about diagnosis,
prognosis, treatment options, and goals of care.
7.
Develop a physician-patient
relationship for shared decision making
 Ensures patients’ values and preferences play a
prominent role
 Addresses ethical obligation to provide full disclosure of
risks and benefits
 Participants should include:
 Patients
 Physicians
 Legal agent in case of loss of decision-making capacity
Fully inform acute kidney injury (AKI), stage 4 and
5 CKD, and ESRD patients about their diagnosis,
prognosis and all treatment options
 AKI patients:
 Decisions about acute RRTx should be made in context of
other life sustaining treatments
 CKD 4-5/ESRD patients:
 In addition to dialysis, treatment options should include not
starting dialysis and/or a time-limited trial of dialysis
Give all patients with AKI, stage 5 CKD, or ESRD an
estimate of prognosis specific to their overall condition
 CKD 5 patients:
 The surprise question together with risk factors for poor
prognosis (age, comorbidities, severe malnutrition, poor
function status) to estimate prognosis
 ESRD patients experiencing major complications:
 When major complications reduce QOL, it is appropriate to
reassess treatment goals
 Consider withdrawal from dialysis
Prognosis
 Estimates should/will impact course of action
 Dated and documented discussions may facilitate
informed decision making
 Estimates can be used to develop consensus on goals of
therapy and care
 Early and continued discussion may facilitate
reassessment in the event of complications that reduce
survival or quality of life
Institute advanced care planning
 Help patients understand his/her condition.
 Prepare for decisions that may have to be made as the
condition progresses over time.
If appropriate, forgo (withhold initiating or withdraw
ongoing) dialysis for patients with AKI, CKD, or ESRD
in certain, well-define situations
 Fully informed patients with DMC, who voluntarily refuse
dialysis or request its discontinuation
 Patients who no longer have DMC or who indicated
refusal of dialysis in an advanced directive
 Patients without DMC, whose properly appointed agent
refuses dialysis or requests its discontinuation
 Patients with irreversible, profound neurological
impairment and lack signs of thought, sensation,
purposeful behavior or awareness of self or environment
Consider forgoing dialysis for AKI, CKD, or ESRD
patients who a very poor prognosis or for whom
dialysis cannot be provided safely
 Patients whose condition renders them unable to
cooperate with the technical process of dialysis
 Patients with terminal illness from non-renal causes
(where no benefit from dialysis is anticipated)
 Patients who meet two or more criteria for statistically
significant poor prognosis.
Time-Limited Trials
 Consider in patients:
 requiring dialysis who have an uncertain prognosis
 for whom a consensus cannot be reached about
providing dialysis
 Agree in advance on the length of the trial and
parameters to be assessed during and at the
completion of the trial to determine whether dialysis
has benefited the patient and whether it should be
continued
Use a systematic approach to communicate
about diagnosis, prognosis, treatment options,
and goals of care
 Good communication improves patients’
adjustment to illness, increases adherence to
treatment and results in higher patient and
family satisfaction
 Patients’ decisions should be based on an
accurate understanding of their condition and
the pros and cons of treatment options.
End of Life Care Preferences
Survey of 584 Stage 4-5 CKD patients
• EOL care needs not integrated into renal care.
• Patients had poor knowledge of palliative care options
and illness trajectory.
• Majority of patients wanted to die at home (36%) or in
inpatient hospice (29%).
• Less than 10% had discussed EOL care with nephrologist.
• Large number (61%) regretted decision to start dialysis!
Davison. Clin J Am Soc Nephrol 5:195-204,2010.
For most dialysis patients, the quality of their lives
determines their acceptance or rejection of medical
interventions to prolong life. Because the quality of their
lives changes, their goals for care and treatment change.
Thus, advance care planning is a dynamic process and
nota single event resulting from one conversation.
Holley J L CJASN 2012;7:1033-1038
Conclusions
 Shared decision making processes are key to assuring the best
choice for a given patient.
 Preparation includes education about modalities and the burdens
inherent in their implementation.
 Advance care planning is a process that must evolve with changes in
a patient’s health care conditions in a changing health care
environment.
 Dialysis may not be the best option for all patients.
 Older patients warrant an age-attuned approach.
HD MORTALITY PREDICTOR
Programmed by Stephen Z. Fadem, M.D., FASN and Joseph Fadem
SERUM ALBUMIN g/dL
SURPRISE QUESTION
I would NOT be surprised if my patient died in the next 6 months.
I would be surprised if my patient died in the next 6 months.
AGE years
DEMENTIA
My patient HAS dementia.
My patient does NOT have dementia.
PERIPHERAL VASCULAR DISEASE
My patient HAS peripheral vascular disease.
My patient does NOT have peripheral vascular disease.
XBETA: -154.59
Predicted Six Month Survival: 89%
Predicted Twelve Month Survival: 74%
Predicted Eighteen Month Survival: 60%
Resources
 TOUCHCALC http://touchcalc.com
 Charlson Comorbidity Score
 Surprise question – hemodialysis predictor score
 Karnofsky score
 Clinical Practice Guideline in the Appropriate
Initiation and Withdrawal from Dialysis, 2nd Edition,
2010
 End of Life Coalition – ESRD Network 5
 http://www.kidneyeol.org/advanced.htm