Conservative management of end stage renal disease and withdrawal of dialysis by ProQuest


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									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                                                  offered dialysis, or when it is withdrawn.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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