Dialysis Decisions: Should Everyone be Dialyzed?
Linda Kirk

Linda J. Kirk, APRN, C, is Renal Clinical Nurse Specialist, South Texas Veterans Health Care System, San Antonio, TX; and a member of ANNA’s Alamo City Chapter and Advanced Practice SIG.

As a member of our hospital ethics committee, I  respond to requests for consults,  along with two other committee members. Last year, my team  received an ethics consult requesting assistance with medical decision making for Mr. D., a 49-year-old male with a long history of paranoid schizophrenia, severe liver disease, and end stage renal disease (ESRD) requiring chronic dialysis for approximately 5 years. Mr. D. refused to be on hemodialysis any longer because his kidneys “were cured.” He had removed his needles during his dialysis treatment. Mr. D. had no advanced directive.

An Ethical Decision-Making Model

Our ethics consult teams use the Jonsen, Siegler, Winslade Decision-Making Model (Jonsen, Siegler, & Winslade, 1998). This ethical decision making model addresses four ethical principles:

1. Medical issues (beneficence): Mr. D. had been on hemodialysis for 5 years, had near end stage liver disease and paranoid schizophrenia with medication noncompliance.
2. Patient preferences (autonomy): The patient was determined to be unable to make decisions. He had no advanced directive and his sister was his legal next of kin. During several discussions with the staff nephrologist, it became clear that Mr. D. wished to stop dialysis.
3. Quality of Life (QOL) issues (non-maleficence): Mr. D. lived in an assisted living facility. He showed up religiously for his dialysis treatments, but usually insisted on stopping treatment early, after anywhere from 15 minutes to 2.5 hours of treatment.
4. Contextual issues (Justice): Mr. D. had infrequent contact with two sisters. He was financially supported by veteran’s benefits, and was managed by an appointed power of attorney. There were also staff safety issues (removed own needles during dialysis treatment).

The sister as the legal medical decision maker decided to withdraw treatment. Mr. D. was referred to inpatient hospice and died peacefully about 3 weeks later.

Creation of Renal Ethics Work Group
The appropriateness of dialysis is a common discussion among staff. After resolving the consult on Mr. D., it became apparent  that we needed to create a Renal Ethics Work Group.  Its purpose was to explore issues related to the appropriateness of hemodialysis in various situations, create a group of informed staff available as consultants when ethical dilemmas related to dialysis occur, and provide future education to hospital staff.

The Renal Ethics Work Group is multidisciplinary including nurses (hospice coordinator, nurse managers, ethics expert nursing school professor), social workers, physicians (palliative care, nephrologist, psychiatrist), psychologists, a chaplain, and a nephrology researcher. Using the Clinical Guideline: Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis (Renal Physicians Association, 2000) to guide our efforts, we are currently writing a hospital policy, incorporating elements of policies from other Veteran Administration hospital dialysis units.

One idea proposes that patients being dialyzed acutely must be re-evaluated prior to being accepted in a chronic dialysis program. We are searching for useful screening tools to objectively evaluate patients whose ability to understand the issues and make a medically informed decision regarding dialysis is questionable. It is also important to offer statistics and prognostic information to assist patients in decision–making.

Contemplate the Issues, Read the Guidelines!
Contemplating all the issues that need to be addressed can be overwhelming. Should we dialyze everyone because we can? Or should we help patients and families find a balance between the burdens and benefits of treatment? Due to long-term relationships between unit staff and dialysis patients, as patient advocates you can initiate end-of-life discussions with your patients (Cooper, 1998). The meaning and quality of life will be different for each patient.

I encourage each of you to read these guidelines and begin by addressing just one recommendation. For instance, how often are advanced directives reviewed with your patients? What percent of your patients even have an advanced directive? Are they reviewed at least yearly or when the medical condition changes? You can  help make tough decisions easier; You can make a difference!

References
Cooper, M.C. (1998). Ethical decision making in nephrology nursing for end-of-life care: a responsibility and opportunity, ANNA Journal 25(6), 603-610, 614.

Jonsen, A.R., Siegler, M., & Winslade, W.J. (1998). Clinical ethics (4th ed.) New York: McGraw Hill.

Renal Physicians Association  (2000). Clinical practice guideline: Shared decision making in the appropriate initiation of and withdrawal from dialysis (2nd ed.). Washington, DC: Author.