Dr. Murtagh from the Department of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom; Dr. Spagnolo from the Department of Educational Sciences & Board of Directors for Bioethics in Rome, Italy; Dr. Panocchia from the Department of Surgical Sciences, Section of Hemodialysis, Gemelli University Hospital, Catholic University, School of Medicine, Renal Program, Rome, Italy, and Dr. Gmbaro from the Division of Nephrology and Dialysis, Columbus-Gemelli University Hospital, Catholic University, School of Medicine, Renal Program, Rome, Italy. [...] the use of advance directives is recommended in the RPA/ASN guidelines and is being utilized by many countries.
Conservative management Research review of end stage renal disease and withdrawal of dialysis Copyright © 2010 Canadian Association of Nephrology Nurses and Technologists patients who are managed conservative- Murtagh, F.E.M., Spagnolo, A.G., ly. This group of patients is important to considered by nephrologists across coun- Panocchia, N., & Gambaro, G. (2009). Conservative (non-dialytic) study, as the care they require can be tries when making decisions for conserv- management of end-stage renal disease similar to those approaching end-of-life ative management: age, co-morbidities, and withdrawal of dialysis. Progress in and palliative care. Little is known about cognitive state, anticipated symptoms Palliative Care, 17(4), 179–186. this subgroup, as research studies tend to and quality of life on the selected path- exclude them, providing a partial picture way, and anticipated prognosis. Reviewed by Kalli Stilos, RN, MScN, of the whole ESRD population. Dialysis patients, in general, are older CHPCN(C), Advanced Practice Nurse, Determining which patients fall into the today, have increased medical issues and Palliative Care Consult Team, subgroup has become clinically and eth- poorer performance status requiring many Sunnybrook Health Science Centre, ically challenging, along with what is the resources to make dialysis available to Toronto, ON best practice for the patients who are not them. Nephrologists question the appro- offered dialysis, or when it is withdrawn. priateness of starting dialysis on these This paper was written by the follow- This article raises a number of issues. ing four physicians: Dr. Murtagh from the older patients. Research has been limited They include: the evidence around sur- in comparing outcomes for older patients Department of Palliative Care, Policy and vival, quality of life, and typical course of Rehabilitation, King’s College London, on dialysis and without dialysis. Research illness following conservative manage- ﬁndings from the United States show that London, United Kingdom; Dr. Spagnolo ment or dialysis withdrawal; criteria used from the Department of Educational 80+ year-old patients commencing dialy- for deciding on conservative management Sciences & Board of Directors for sis have a modest survival rate (Kurella, or withdrawing dialysis, and how they are Bioethics in Rome, Italy; Dr. Panocchia Covinsky, Collins, & Chertow, 2007). justiﬁed; decision-making process when from the Department of Surgical Sciences, Judging a patient by his or her age also patients are cognitively impaired and can- Section of Hemodialysis, Gemelli raises many ethical issues such as justice not make decisions for themselves. University Hospital, Catholic University, and equity. It is important that each The decision criterion for initiating School of Medicine, Renal Program, patient is attended to in a holistic, patient- dialysis is controversial. Some nephrolo- Rome, Italy; and Dr. Gambaro from the gists feel patients with irreversible, pro- centred approach and the additional fac- Division of Nephrology and Dialysis, found neurological impairment are not tors like patient wishes, quality of life, Columbus-Gemelli University Hospital, suitable for dialysis while others feel that prognosis and concurrent medical issues Catholic University, School of Medicine, no patient is too sick for dialysis. The are addressed in the equation. Renal Program, Rome, Italy. Renal Physicians Association (RPA) and Nephrologists question whether it is This article outlines that the end stage the American Society of Nephrology reasonable to dialyze patients with multi- renal disease (ESRD) population is pro- (ASN) developed guidelines for the with- ple co-morbidities. Levinsky (2003) gressively increasing in developing coun- holding or withdrawing of dialysis: notes the difﬁculty of predicting survival tries; the majority of patients being the Shared Decision-Making in the Appropriate and quality of life for patients with co- elderly with multiple health issues and Initiation of and Withdrawal from Dialysis. morbidities and believes it is better to poor performance status. Nephrologists In 1990 and 2005, the RPA/ASN con- dia
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