Journal Departments

Controversies in Nephrology Nursing

Should Dialysis Be Offered to All Patients?
Christy Price Rabetoy, Department Editor

Some Patients Should Not Be Given the Option of Dialysis
Jennifer Payton, MHCA, BSN, RN, CNN
Home Training Coordinator
Dialysis Clinic, Inc
Goose Creek, SC
Southeast Region Health Policy Advisor
Member, ANNA’s Palmetto Chapter

Dialysis should only be offered to a patient or family if it will increase the quality as well as the quantity of a patient’s life. I think we forget that the quality of our life is more important than the quantity of our life. Many times, families want to keep their loved ones alive at all costs. This is when skilled physicians and nurse practitioners should come into the picture. Instead of dangling the “dialysis carrot” in front of these people, they should be laying out the facts. If dialysis will have no hope of improving the quality of a patient’s life, it should not be used solely to increase the quantity of life. Just as we individualize our care based on each patient’s specific needs, we need to individualize our decision to offer dialysis as an option to all patients.

In the transplant community, it is well known that not all patients are offered transplants. Patients who are morbidly obese, have drug addictions, or have multiple co-morbid conditions are not offered the option of transplant. Giving transplants to these patients could be seen as a “waste” of organs. Why then do we “waste” resources in the dialysis community by dialyzing very ill patients? I have personally seen patients in the outpatient hemodialysis unit who should not have been started on dialysis. I had one patient who would come to dialysis via a stretcher from a local nursing home. This patient did not know where he was or why he was there. The patient was incontinent, contracted, and had to be fed through a feeding tube. This patient, who was unable to communicate and virtually unresponsive, was started on dialysis in this grave condition. In my opinion, the patient’s family should not have been offered the option of dialysis.

My opinion is both professional and very personal as my family went through this trauma several years ago. One of my family members injected cocaine into her portacath. She had the port due to her multiple health problems and frequent hospitalizations. She ended up on a ventilator in the ICU with multi-system organ failure. As her situation deteriorated, her kidneys began to fail as well. My family member was not able to make the decision regarding dialysis because of her condition. After encouragement from the nephrologist, my family was willing to try anything and therefore agreed to dialysis. A week later, my family stopped the ventilator and she died. In my opinion, the use of dialysis in this case just prolonged her suffering, my family’s suffering, and the dying process. This is clearly a case of where dialysis was used to increase the quantity and not the quality of someone’s life.

Years ago, patients with kidney disease had to go through a screening process to be started on dialysis. It now seems as if dialysis is offered to everyone. Dialysis is even offered to the chronically ill patients who have little quality of life. People forget that dialysis and transplant are not the only options. The choice of not initiating dialysis is also an option. In our technologically advanced society, we sometimes keep patients alive just because the technology exists, and I believe this is wrong.

The Issue May Not Be Whether, But How You Offer Dialysis
Christine Ceccarelli, MS, MBA, RN
Staff Nurse
Hartford Hospital
Hartford, CT
and Central Connecticut Dialysis Unit
Meriden, CT
Member, ANNA’s Ethics Committee & ANNA’s Colonial Chapter

Every day, nephrology nurses care for patients with life-threatening illnesses and poor prognoses for recovery. The patient may be in an intensive care environment with multi-system organ failure or may be an outpatient compromised by age, limited function, or other end-stage medical problems. The effort can seem futile, even inhumane and cruel, as it prolongs a life destined to end due to physiological failure. Sometimes, we know the patient and family well; sometimes, we don’t. But we all make judgments about the appropriateness of the situation, based on our own values, preferences, and experiences. “Why is this person on dialysis?” is a question often discussed in lunchrooms and at nurses’ stations.

The question of appropriateness of life-extending therapies has been discussed as their use has outstripped our society’s ability to deal with this issue. It became a societal norm to often initiate therapy and then wonder whether it should have been started in the first place. However, things are changing. Discussions about when to use therapies and how to approach patients and families in making these decisions can readily be found in professional literature. Our competency in dealing with this issue is increasing, but many feel it is taking too long. As use of dollars for essential health care is scrutinized and professional caregiver resources dwindle, the problem seems more urgent. How can we reverse the transgressions of offering therapies to everyone when we know the outcome will be poor? Perhaps the answer lies in our behavioral competence more than in our clinical knowledge.

Patients and their families facing these tough decisions have often not thought about or discussed their possibility in advance, despite our best efforts. Although preparation of advance directives are encouraged, they are not yet widely used. Death, as a natural end to life, is a private and feared experience in our society, usually viewed for its negative effects on those left behind. The positive impact of palliative care in providing peace and comfort to patients and families is not part of common knowledge. Therefore, the option of foregoing life-sustaining treatment is often poorly received despite a rational description of its futility. When the life of a loved one is threatened, thoughts first turn to anticipation of personal loss, and the emotions that accompany this terrifying possibility. In addition, cultural and religious beliefs feed into a personal interpretation of what is “right” in terms of extending life, and efforts to withhold any treatment can be interpreted as passive euthanasia.

In many of these cases, offering dialysis to extend life is inappropriate according to the judgment of caring healthcare professionals. In an effort to avoid initiating dialysis treatment, should the patient and/or family be apprised of this decision? Is it ethical to withhold information about declining renal function? If this information is shared but the option of dialysis is not, is this ethical practice? Is the amount of information discussed dependent on the educational or socioeconomic level of the patient and/or family? Is this a discriminatory practice? All of these questions are important to answer and must be discussed by the healthcare team.

As difficult decisions need to be made, particularly by families when the patient is no longer competent, a careful assessment of factors influencing their decision-making can be a good first step. Involving the whole team in discussion of each family’s dynamics, preferably at a time before critical decisions are needed, will assist to create a unified plan of communication and support. Some families need time to process the realities of their loved one’s condition. Guilt and perception of abandonment can lead to insistence on continued therapies. Anticipatory grief is often experienced at these times with family members caught in the “shock and denial mode” when the suggestion of foregoing dialysis occurs. In other cases, family members may differ in their attitudes and opinions, requiring ongoing facilitation of decision-making. If the family is told that dialysis may not be appropriate and this decision is initially rejected, a dialysis trial may be helpful in providing the time needed for a more permanent decision. As the professionals providing direct care of their loved one, nurses can be the critical link to families who may feel judged and abandoned if they reject a medical recommendation not to initiate therapy.

In all cases, remembering that we have been through this scenario more than once, and the patient or family has not, will assist us to continue supporting them despite our frustration and angst. Whatever the circumstances, patients and families deserve complete information when this is desired, and must be part of the decision-making process, even though the outcome may not be what we ourselves would choose.

The Controversies in Nephrology Nursing department focuses on exploring ethical and clinical issues within the nephrology clinic practice in a point/counterpoint format. Address correspondence to: Christy Price Rabetoy, Department Editor, through the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856) 256-2320; or by emailing her at christycpr@comcast.net. You may also log onto this column at www.nephrologynursingjournal.net (clink on Department link) and email your comments to the Editor (see Discussion Area). The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.