Dialysis in the Elderly Has It Lived Up to

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					  Dialysis in the Elderly:
Has It Lived Up to Expectations?
   Should Age Be a Factor in
     Nephrology Referrals?

      Mark T. Hughes, MD, MA
          Assistant Professor of Medicine
     Core Faculty, Berman Institute of Bioethics
    Johns Hopkins University School of Medicine

                  ACP Maryland
                 February 8, 2008
              Disclosures
• No financial or other conflicts of interest
                  Goals
1. Review different approaches in the
   theory of justice in relation to allocation
   of scarce resources
2. Discuss age as a factor in rationing
   decisions at the societal level
3. Present ethical issues encountered at
   the individual level
          Theories of Justice:
        Allocation of Resources
• Libertarian:   linked to autonomy
• Utilitarian:   grounded in beneficence and
                 non-maleficence
• Egalitarian:   linked to equality (reduction
                 or amelioration of inequality)

• Communitarian:      tied to social/relational
                      aspects of life
     A      60                                   B      60


            50                                          50


            40                                          40
  Utiles                                      Utiles
(Well-being, 30                             (Well-being, 30
  Survival,                                   Survival,
QALYs, etc.)                                QALYs, etc.)
             20                                          20


            10                                          10


             0                                           0
                  5th     50th       95th                     5th     50th       95th
                        Percentile                                  Percentile
      C     60
                                                 D      60


            50                                          50


            40                                          40
  Utiles                                      Utiles
(Well-being, 30                             (Well-being, 30
  Survival,                                   Survival,
QALYs, etc.)                                QALYs, etc.)
             20                                          20


            10                                          10


             0                                           0
                  5th     50th       95th                     5th     50th       95th
                        Percentile                                  Percentile
     A      60                                   B      60


            50                                          50


            40
                        Utilitarian equivalence         40
  Utiles                                      Utiles
(Well-being, 30                             (Well-being, 30
  Survival,                                   Survival,
QALYs, etc.)                                QALYs, etc.)
             20                                          20


            10                                          10


             0                                           0
                  5th     50th       95th                     5th     50th       95th
                        Percentile                                  Percentile
      C     60
                                                 D      60


            50                                          50


            40                                          40
  Utiles                                      Utiles
(Well-being, 30                             (Well-being, 30
  Survival,                                   Survival,
QALYs, etc.)                                QALYs, etc.)
             20                                          20


            10                                          10


             0                                           0
                  5th     50th       95th                     5th     50th       95th
                        Percentile                                  Percentile
     A      60                                   B      60


            50                                          50


            40                                          40
  Utiles                                      Utiles
(Well-being, 30                             (Well-being, 30
  Survival,                                   Survival,
QALYs, etc.)                                QALYs, etc.)
             20                                          20


            10                                          10


             0                                           0
                  5th     50th       95th                     5th     50th       95th
                        Percentile                                  Percentile
      C     60
                                                 D      60


            50                                          50
                  Maximin Approach
            40                                          40
  Utiles                                      Utiles
(Well-being, 30                             (Well-being, 30
  Survival,                                   Survival,
QALYs, etc.)                                QALYs, etc.)
             20                                          20


            10                                          10


             0                                           0
                  5th     50th       95th                     5th     50th       95th
                        Percentile                                  Percentile
     A      60                                   B      60


            50                                          50


            40                                          40
  Utiles                                      Utiles
(Well-being, 30                             (Well-being, 30
  Survival,                                   Survival,
QALYs, etc.)                                QALYs, etc.)
             20                                          20


            10                                          10


             0                                           0
                  5th     50th       95th                      5th     50th       95th
                        Percentile                                   Percentile
      C     60
                                                 D      60


            50                                          50
                                                              Egalitarian Approach
            40                                          40
  Utiles                                      Utiles
(Well-being, 30                             (Well-being, 30
  Survival,                                   Survival,
QALYs, etc.)                                QALYs, etc.)
             20                                          20


            10                                          10


             0                                           0
                  5th     50th       95th                      5th     50th       95th
                        Percentile                                   Percentile
     A      60                                   B      60


            50                                          50

                                     Utilitarian Approach
            40                                          40
  Utiles                                      Utiles
(Well-being, 30                             (Well-being, 30
  Survival,                                   Survival,
QALYs, etc.)                                QALYs, etc.)
             20                                          20


            10                                          10


             0                                           0
                  5th     50th       95th                      5th     50th       95th
                        Percentile                                   Percentile
      C     60
                                                 D      60


            50                                          50
                  Maximin Approach                            Egalitarian Approach
            40                                          40
  Utiles                                      Utiles
(Well-being, 30                             (Well-being, 30
  Survival,                                   Survival,
QALYs, etc.)                                QALYs, etc.)
             20                                          20


            10                                          10


             0                                           0
                  5th     50th       95th                      5th     50th       95th
                        Percentile                                   Percentile
    How to Allocate Resources
• Look for those who can pay
• Look for those who are “deserving”
  – Individual effort, merit, social contribution
• Look for those who are worst off
• Look for those who will most benefit
 Age as a criterion for allocation
• Libertarian:   would be opposed
• Utilitarian:   may favor young on balance,
                 but depends on utiles counted
                 and size of segment of
                 population
• Egalitarian:   may see age cutoff as
                 inequality, but maybe not if
                 take lifespan view
        Moment of time view
• Two people at same time have equal claim
• Usually resolved by “first come, first served”
• If exactly same time, then triage:
  – Non-combat:        the sickest gets the resource
  – Disaster/Combat:   the one most likely to
                       benefit (fight another day)
                       gets the resource
        Over the lifetime view
• Norman Daniels: Prudential Life Span Account
• Each age group represents stage in person’s life
  span.
• As prudent deliberators, people would allocate
  scarce resources over a lifetime in a way that
  improved chances of attaining a normal life span
• People would reject pattern that reduced chances
  of living to a normal life span
  Prudential Life Span Account
• You know you have 5 years to live without the
  resource (dialysis):
   – You are age 80 and will live to 85
   – You are age 40 and will live to 45


• Most people would choose to shift resources to
  the treatment of younger person to maximize
  chances of living to normal life span
   The “fair innings” argument
• Everyone entitled to some “normal” life span
• The old have had an opportunity to live more
  years; the young deserve a chance to live
  those additional years
• Those falling short of “normal” life span are
  “cheated”
• Those exceeding the “normal” life span are
  living on “borrowed time.”
       Communitarian account
• Daniel Callahan: defined age cut-off
• Society should guarantee basic care to all,
  including provision of palliative care.
• Once individuals reach natural life span, no efforts
  to extend their lives; only measures to relieve
  suffering.
• On this view, the elderly have achieved life’s
  possibilities and view death as relatively
  acceptable.
             Modifying the Callahan view
                         (Robert Veatch)

              Callahan                         Veatch

Points for                        Points for
Life-                             Life-
Sustaining                        Sustaining
Treatment                         Treatment




                           75
                   Age                           Age
    Arguments against age as a factor
• Ageism as a prejudice
• Stereotyping the elderly
• Treating elderly as scapegoats for costs
• Creating intergenerational conflict
• Unfair to deny elderly new technologies that they
  did not have access to (and their taxes helped
  develop)
• Hard to predict when last year of life is (when a
  quarter of Medicare budget is spent)
       Individual ethical issues
• Respect for autonomous decisions
  – Understanding personal values/preferences
  – Informed consent/shared decision-making
• Beneficence: four levels of the patient’s good
  – Defining the good for this patient
• Truthtelling: pros/cons of dialysis, prognosis
• Dealing with uncertainty
• Phronesis: practical judgment
         NKF K/DOQI GUIDELINES:
      Clinical Practice Guidelines and Clinical Practice
                      Recommendations
                        2006 Updates
                   Hemodialysis Adequacy

“…the recommended timing of dialysis therapy
initiation is a compromise designed to maximize
patient QOL by extending the dialysis-free period
while avoiding complications that will decrease
the length and quality of dialysis-assisted life.”
Thank you
         (A) Kaplan–Meier
         survival curves for
         those with
         ischaemic heart
         disease, comparing
         the dialysis and
         conservative
         groups (log rank
         statistic 1.46, df 1,
         P = 0.27).

         (B) Kaplan–Meier
         survival curves for
         those without
         ischaemic heart
         disease, comparing
         the dialysis and
         conservative
         groups (log rank
         statistic 12.78, df
         1, P < 0.0001).
                                    Murtagh, F. E. M. et al. Nephrol. Dial. Transplant. 2007 22:1955-1962;
                                    doi:10.1093/ndt/gfm153

Copyright restrictions may apply.
  Kaplan-Meier survival curves for those with high comorbidity (score = 2), comparing dialysis and
                              conservative groups (log rank statistic




                  Murtagh, F. E. M. et al. Nephrol. Dial. Transplant. 2007 22:1955-1962;
                  doi:10.1093/ndt/gfm153


Copyright restrictions may apply.
  Kaplan-Meier survival curves comparing the dialysis and conservative groups (log rank statistic =
                                             13.63, P




                  Murtagh, F. E. M. et al. Nephrol. Dial. Transplant. 2007 22:1955-1962;
                  doi:10.1093/ndt/gfm153


Copyright restrictions may apply.
          60


          50


          40

Well-being
(Utiles or 30
 QALYs)

          20


          10


           0
                10th             50th              90th
                              Percentile

                   Pattern of distribution of the good
          60


          50


          40

Well-being
(Utiles or 30
 QALYs)

          20


          10


           0
                10th             50th              90th
                              Percentile

                   Pattern of distribution of the good
          60


          50


          40

Well-being
(Utiles or 30
 QALYs)

          20


          10


           0
                10th             50th              90th
                              Percentile

                   Pattern of distribution of the good
          60


          50


          40
Well-being
(Utiles or 30
 QALYs)
          20


          10


           0
                10th              50th              90th
                               Percentile

                Pattern of distribution of the good
                Linear (Pattern of distribution of the good)
Table 1. Physicians Questionnaire Scenarios (Wilson R, et al. AJKD 2001)

The angina scenario
Suppose Mr Jones has a creatinine level of 950 mumol/L and some uremic
symptoms. He is 55 years old. He has had two prior myocardial infarctions and it is
believed he would not benefit from bypass surgery. He is on optimal medical
therapy.For each of the following statements, indicate the likelihood that you would
refer this patient to a nephrologist for a consideration for dialysis (circle one number)
a. He has angina only with heavy exertion.
Definitely not refer 1
Probably not refer 2
Uncertain 3
Probably refer 4
Definitely refer 5
b. He has angina after walking a mile.
c. He has angina after walking 100 yards.
d. He has angina after walking 50 yards.
e. He has angina at rest.
The cancer scenario

Mr. Jones has a creatinine level of 950 mumol/L and some
uremic symptoms. He is 55 years old. He does not have
heart disease.
a) He had Hodgkins disease diagnosed a year ago and is
currently in remission (5-year remission rate, 75%-85%).
b) He had Duke's stage C carcinoma of the colon resected
1 year ago and is receiving chemotherapy (5-year survival
rate, 40%).
c) He had multiple myeloma diagnosed 1 year ago and is
receiving chemotherapy (1-year survival rate, 26%).
d) He has metastatic malignant melanoma and is receiving
palliative care. He uses morphine for pain.
The mental status scenario

Mr. Jones has a creatinine level of 950 mumol/L and some
uremic symptoms. He is 55 years old. He does not have
heart disease, diabetes, or cancer.
a) He is depressed but not suicidal.
b) He is depressed and suicidal.
c) He has chronic schizophrenia and a tendency to violence
if confined.
d) He has Alzheimer's disease and will require institutional
care within 2-3 months.
e) He has a mental age of 8 years. He lives in a group home
for the developmentally disabled.
The social scenario

Mr. Jones has a creatinine level of 950 mumol/L and some
uremic symptoms. He is 55 years old. He does not have heart
disease, diabetes, or cancer.
a) He is employed and lives with his wife, who also works.
They have no children.
b) He is depressed and suicidal.
c) He is unemployed and on welfare. His wife does not work.
They have two children.
d) He is employed and lives with his wife, who is physically
disabled (uses a wheelchair). They have two children.
e) He is employed. He lives a promiscuous gay lifestyle. He
refuses to be tested for human immunodeficiency virus.
               Survey results regarding age
    Wilson R, et al. End-stage renal disease: Factors affecting referral decisions by family
    physicians in Canada, the United States, and Britain. Am J Kid Dis 2001; 38(1):42-48


●   65% American/Canadian physicians refer for
    dialysis regardless of age
●   49% British physicians would refer for dialysis
    regardless of age
●   Mean age for non-referral: 85 (US/Canada)
                               82 (Britain)
●   Non-referral: Women (85 years); men (83years)