Rebecca J. Schmidt, DO, FACP, FASN Professor of Medicine and Chief, Section of Nephrology West...

Rebecca J. Schmidt, DO, FACP, FASNProfessor of Medicine and Chief, Section of Nephrology

West Virginia University School of Medicine WVU Healthcare

June 29, 2012

Introduction and BackgroundFastest growing sector of incident ESRD are older patientsEstimated that 47% of individuals > 70 have CKDProportion > 65 starting dialysis has increased ~10%/yr

Overall increase of 57% between 1996 and 2003Elderly (> 75) have high prevalence of comorbid conditionsClinical guidelines are not age-specificPathophysiology and natural history of CKD in the elderly

differs from that of younger patientsArmamentarium of tools for patient education evolving

Learning ObjectivesTo understand the rationale for taking an age-attuned

approach when providing informed consent to older patients with chronic kidney disease (CKD).

To recognize the characteristics that signify a poor prognosis in the older CKD patient.

To be prepared to address specific issues in informed consent discussions with older CKD patients.

OutlineOptions and ethical issuesLikelihood of renal disease progression before deathImpact of age, functional status, comorbid conditions

and dialysis on survivalBurdens of dialysis and risk to quality of lifeInforming prospective dialysis patients about the

contingencies of their consentSpecific issues to address in informed consent

discussions with older patients

Case Presentation

A 78 year old white female was referred for CKD care with an eGFR of 39 ml/min/1.73m2 and anemia. She also had DM, HTN, CAD, ICM, HLD, MDS and PVOD. Her renal function remained stable for the next 7 months, after which the patient missed all CKD clinic appointments until referred back again by her PCP 2 years later, having sustained 2 additional myocardial infarctions requiring placement of 5 coronary artery stents. Her eGFR was now 30 ml/min/1.73m2, and she was advised that hemodialysis might be difficult consequent to cardiac disease and other comorbid conditions. As her GFR fell to 15 ml/min/1.73m2, the patient decided to pursue dialysis because she wanted "to live for my family.” Her family was supportive of this stance, stating "we have to do everything we can.”

Options and Ethical Issues/QuestionsRenal replacement therapy optionsPatient preferences, competence, and understandingExpectations regarding quantity and quality of lifeContextual issuesWhat is “everything?’Does opportunity command obligation?

Options

Renal Replacement TherapyHemodialysisPeritoneal dialysisHome dialysisTransplantation

No Renal Replacement Therapy

Typical Illness Trajectories For Chronic Illness

Murray S A et al. BMJ 2005;330:1007-1011

Trajectories of Illness

Holley J L CJASN 2012;7:1033-1038

©2012 by American Society of Nephrology

Trajectory of Illness for ESRD

Trajectory of Functional Decline in the Last Year of Life

Murtagh JAGS 59:304-308, 2011

Patient ChallengesAccepting and coping with chronic conditionAccepting disruption of current lifeFinding the financial resourcesDealing with uncontrollable consequencesDealing with loss of independence and controlAccepting changes in role (family, friends, work)Maintaining meaning to lifeConfronting one’s own mortality

Provider Challenges

RJ Schmidt and BS Pellegrino, Guest Editors. Primary Care of the Patient with Chronic Kidney Disease.

Advances in CKD 18:6, 2011.

Expected remaining lifetimes (years) of the U.S. population & of dialysis & transplant patients, by age, gender, & race Table 6.b (Volume 2)

U.S. data: calculated from Tables 1–9 in the United States life tables (Arias E). Available at http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_09.pdf. ESRD data: prevalent dialysis & transplant patients, 2007. Expected remaining lifetimes by race & gender can be found in Reference Table H.31. Prevalent ESRD population, 2007, used as weight used to calculate overall combined-age remaining lifetimes.

General U.S. population, 2004 ESRD patients, 2007All races White African American Dialysis Transplant

All M F All M F All M F All M F All M F0-14 71.4 68.8 73.9 71.8 69.2 74.3 67.2 63.7 70.3 19.8 20.5 19.1 55.0 54.7 55.615-19 61.6 59.1 64.1 62.0 59.5 64.4 57.5 54.0 60.6 17.6 18.5 16.6 42.4 42.0 43.020-24 56.9 54.4 59.2 57.2 54.8 59.5 52.7 49.4 55.7 14.9 15.8 13.9 38.4 38.0 39.125-29 52.1 49.7 54.4 52.5 50.1 54.7 48.1 44.9 50.9 13.2 13.9 12.3 35.1 34.7 35.930-34 47.4 45.1 49.5 47.7 45.4 49.8 43.5 40.5 46.2 11.4 11.8 10.8 31.3 30.8 32.235-39 42.7 40.4 44.7 42.9 40.7 45.0 39.0 36.0 41.5 9.9 10.3 9.5 27.8 27.2 28.840-44 38.0 35.8 40.0 38.3 36.1 40.2 34.5 31.6 37.0 8.6 8.8 8.4 24.3 23.7 25.445-49 33.5 31.4 35.4 33.7 31.7 35.6 30.3 27.5 32.6 7.4 7.5 7.3 21.1 20.5 22.350-54 29.2 27.2 30.9 29.3 27.4 31.1 26.3 23.7 28.5 6.5 6.6 6.4 18.1 17.4 19.355-59 25.0 23.1 26.5 25.1 23.3 26.6 22.6 20.1 24.5 5.6 5.7 5.6 15.5 14.8 16.760-64 21.0 19.3 22.4 21.0 19.4 22.4 19.1 16.9 20.7 4.8 4.8 4.9 13.1 12.4 14.265-69 17.2 15.7 18.5 17.3 15.8 18.5 15.9 14.0 17.2 4.1 4.0 4.1 10.8 10.2 11.870-74 13.8 12.5 14.8 13.8 12.5 14.8 13.0 11.4 14.0 3.4 3.4 3.5 8.9 8.4 9.875-79 10.8 9.7 11.5 10.7 9.6 11.5 10.4 9.1 11.2 2.9 2.8 2.9 7.5 7.0 8.380-84 8.2 7.3 8.7 8.1 7.2 8.6 8.3 7.3 8.7 2.4 2.3 2.585+ 4.4 3.9 4.6 4.3 3.8 4.5 5.0 4.4 5.1 1.9 1.9 2.0Overall 25.2 23.4 26.6 25.3 23.6 26.7 23.1 20.9 24.8 5.9 6.0 5.9 16.4 15.8 17.4

USRDS 2009

2003 2005 2007 RR CI RR CI RR CI66–69 1 1 170–74 1.33 1.29 - 1.38 1.34 1.29 - 1.38 1.35 1.3 - 1.475–84 2.34 2.28 - 2.42 2.38 2.31 - 2.46 2.38 2.31 - 2.4685+ 6.30 6.11 - 6.49 6.43 6.24 - 6.62 6.34 6.15 - 6.55Male 1.16 1.14 - 1.17 1.14 1.12 - 1.15 1.13 1.11 - 1.15Female 1.00 1.00 1.00White 1.00 1.00 1.00African American 1.13 1.1 - 1.16 1.16 1.13 - 1.19 1.15 1.12 - 1.18Other 0.87 0.83 - 0.9 0.82 0.79 - 0.86 0.85 0.82 - 0.89No CKD, DM, or CVD 1.00 1.00 1.00CKD (NDM, non-CVD) 1.99 1.83 - 2.17 1.60 1.47 - 1.74 1.72 1.6 - 1.85DM (non-CKD, non CVD) 1.23 1.19 - 1.28 1.22 1.18 - 1.27 1.12 1.08 - 1.16CVD (non-CKD, non-DM) 1.84 1.8 - 1.88 1.81 1.78 - 1.85 1.80 1.76 - 1.83CKD+DM 2.10 1.86 - 2.37 2.05 1.84 - 2.28 1.80 1.63 - 1.98CKD+CVD 3.10 2.98 - 3.22 2.85 2.74 - 2.96 2.77 2.67 - 2.86DM+CVD 2.45 2.39 - 2.51 2.36 2.3 - 2.42 2.19 2.13 - 2.25CKD+DM+CVD 4.07 3.91 - 4.24 3.57 3.43 - 3.71 3.35 3.23 - 3.47Hypertension 0.81 0.8 - 0.82 0.81 0.8 - 0.83 0.81 0.8 - 0.83Liver disease 1.70 1.6 - 1.81 1.79 1.69 - 1.9 1.84 1.73 - 1.95GI disease 1.24 1.21 - 1.28 1.26 1.22 - 1.3 1.25 1.21 - 1.29Cancer 1.86 1.83 - 1.9 1.84 1.8 - 1.87 1.80 1.76 - 1.83COPD 1.98 1.94 - 2.01 1.96 1.93 - 1.99 1.95 1.92 - 1.99Anemia 1.70 1.67 - 1.73 1.71 1.68 - 1.74 1.72 1.69 - 1.75

Predictors of mortality in Medicare patients age 66 & older, by age, gender, race, at-risk group, & comorbidityTable 5.b (Volume 1)

Point prevalent on January 1 of each year, age 66 & older. Comorbidities identified from claims in prior year, and exclude patients enrolled an HMO, with Medicare as secondary payor, or diagnosed with ESRD in the prior yearFollowed from January 1 to December 31 of the year, censored at ESRD date and the end of Medicare entitlement. Results are from multivariable Cox regressions.

USRDS 2009

Nordio et al. American Journal of Kidney Diseases 2012; 59:819-828 (DOI:10.1053/j.ajkd.2011.12.023 )

Unadjusted & Adjusted All-Cause Mortality Rates in Medicare CKD & Non-CKD Patients, by AgeFigure 4.16 (Volume 1)

Point prevalent Medicare patients age 66 & older. Adj: gender/race/hospitalization/comorbidity; ref: 2005 cohort.

Likelihood of Renal Disease Progression before Death

Cumulative incidence of

end-stage renal disease (ESRD), cardiovascular

death, and non-cardiovascular death during

follow-up

Dalrympal. J Gen Intern Med 26(4):379-85, 2010.

Conway et al. Nephrol. Dial. Transplant. 2009;24:1930-1937

(A) Proportion of patients surviving by age group at referral. Curves are generated from the Cox regression equation and are adjusted for baseline haemoglobin, eGFR and diastolic blood pressure and early rate of change in renal function.

(B) Cumulative risk of likelihood of renal replacement therapy by age at referral. Curves are generated from the failure function of the Cox regression equation and are adjusted for early rate of change in eGFR and level of proteinuria, haemoglobin and eGFR at referral.

Conway et al. Nephrol. Dial. Transplant. 2009;24:1930-1937

Likelihood of Renal Disease Progression before DeathGFR of <30Progressive, irreversible deterioration in kidney

function over reasonable period of observationPresence of diabetesPresence of proteinuria

Indicators of Poor PrognosisMarked functional impairmentFrailtyHistory of fallsInability to transfer Serum albumin below 3.5 gm/dlYes to the surprise questionHigh Charlson Comorbidity Scores

Frailty is ImportantGeneral population:

Frailty criteria met by 7% > 65 and 40% >80 yearsFried. J Gerontol A Biol Sci Med Sci. 56:M146-M156, 2001

Elderly CKD patients:Frailty with CKD is increased 2-F and 6-F if GFR < 45 (even

corrected for comorbid)Frailty + CKD = increased death

Wilhelm. Am J Med. 122:664-671, e2, 2009Elderly ESRD patients:

74% in 60-70 age group; 79% in over 80 age groupRisks of death 2.24 and hospitalization 1.56 for frail pts

Johansen. J Am Soc Nephrol .18:2960-2967

Living Status and Residence during the Study Period, Assessed at 6-Month Intervals.

Jassal SV et al. N Engl J Med 2009;361:1612-1613.

Change in Functional Status after Initiation of Dialysis.

Kurella Tamura M et al. N Engl J Med 2009;361:1539-1547.

Malnutrition Linked to Mortality in Dialysis Patients

Undernourished, small (low BMI) with low albumin and BUN levels have poorest survival

Albumin <4 g/dl single lab finding of importDecrease in albumin is dose-dependentOR 1.48 for albumin 3.5-3.9; 3.13 for albumin 3.0-3.4

Does not prove cause and effectMeaning of hypoalbuminemia may differ among HD vs.

PD patients but malnutrition by SGA and initial fat-free body mass independently predicts death

Chung 2000 Goldwasser 1994Owen 1993 Keshiaviah 1994Lowrie 1990

Surprise QuestionWould I be surprised if this patient died in the next

year?

Moss, Clin J Am Soc Nephrol 3:1379-1384, 2008

Characteristics Signifying a Poor Prognosis

High comorbidity scores (e.g., modified Charlson Comorbidity Index score of ≥ 8)

Marked functional impairment (e.g., Karnofsky Performance Status Scale Score < 40)FrailtyHistory of fallsInability to transfer

Severe chronic malnutrition (e.g., serum albumin level < 2.5 g/dL using the bromcresol green method)

Nephrologist would not be surprised at their deathRPA Clinical Practice Guideline in the Appropriate Initiation and Withdrawal from

Dialysis, 2nd Edition, 2010.Johansen. J Am Soc Nephrol 18:2960-2970, 2007.

Arnold. N Engl J Med 361: 1597-1598, 2009..

Case Presentation - continued She was not keen on peritoneal dialysis, so an AVF was placed and the patient was followed in the CKD Clinic awaiting the appropriate time to start dialysis. When she had her fifth heart attack and another PTA, signs of pulmonary edema prompted the decision to start dialysis; however, the AVF was poorly functional and she ultimately required placement of a TCC to achieve meaningful dialysis. The TCC required several replacements for which she traveled the 4-hour round trip to the hospital for this procedure and on several occasions underwent an urgent dialysis treatment for volume overload by virtue of a missed treatment because of no access. Revision and/or recreation of vascular access were deferred for 6 months for cardiac reasons and 5 months later, she was admitted for GI bleeding, developed chest pain and underwent additional coronary artery PTA and stents.

Impact of Dialysis on Survival

Survival benefit for selected sicker patients choosing dialysis over palliative care is small And not uniform

Couchoud 2009, Carson 2009, Murtagh 2007, Joy 2003, Brunori 2008, Elam 2009

No survival benefit to dialysis in the sickestBetter survival with dialysis unless CVDz or comorbiditiesMore of those on dialysis died while hospitalized (65%) than

those choosing no dialysis (27%).Smith. Clin Nephron Practice 2003

Murtagh. Nephrol Dial Transplant 2007

Kaplan-Meier survival curves for those with high comorbidity (score=2), comparing 5 dialysis and conservative groups (log rank statistics <0.001, df 1, P=0.98.

Murtagh. Nephrol Dial Transplant. 2007; 22(7):1955-62

Dialysis May Not Mean Greater Survival in Older Patients with Poor Prognosis

Impact of Age, Clinical Status and Dialysis on SurvivalOlder age and co-morbid conditions are key prognostic

indicators. Likelihood of progression to ESRD prior to death is an

important consideration.Dialysis may not confer a survival benefit over active non-

dialytic management in patients with a poor prognosis.

Case Presentation - continued Further vascular access surgery was again delayed until several months later when, with the blessing of her cardiologist, the patient was approached about AVF placement, but was dissuaded by her children, who were convinced that her previous heart attack had been precipitated by the vascular access surgery and did not wish her to spend any more time traveling to the hospital 100 miles distant. She continued to live in her home but required increasing support from her family for ADLs and had little energy to enjoy even crochet despite receiving repeated transfusions for ESA-refractory anemia.Several months later, she suffered a cardiac arrest one morning as she was dressing to come to dialysis.

Presents to CKD Clinic with

eGFR 39 ml/min

After 7 months, lost to followup for 24 months;

eGFR still 39 ml/min

Stable AP; starts ESA and Fe therapy at

CKD Clinic; CKD options presented

AMI with pulmonary

edema; ER HD started via TCC

(AVF nonfx)

Recurrent AP and PTA; GI bleed; continues with

TCC

Now s/p AMI x 2 and PTA x 5; many

transfusions for MDS; eGFR 30

ml/min

HD chosen and AVF placed

TCC replaced x 3; AVF surgery deferred b/o CVDz; several transfusions

Jan 2011-June 2011May 2010-Dec 2010Jan 2010-April 2010May 2007-Dec 2009

Died at home

Options Renal Replacement TherapyNo Renal Replacement Therapy

By decisionActive non-dialytic managementHospice and palliative care

By defaultEmergency dialysis startDeath

Cohen L M et al. CJASN 2010;5:72-79

Older ageDementiaPVODLow albuminSurprise ?

Survival across quartiles of predicted risk

Prognostic Indicator Estimates at the Start of Dialysis

Parameter Result

Charlson Comorbidity Index 10.8 (very high)Surprise Question No Karnofsky Score 50%

Hemodialysis Mortality Predictor 12 month survival - 30%18 month survival - 12%

Serum albumin at dialysis start 3.2 mg/dl (50% 1-yr mortality)Fistula Failure to Mature Risk 7.5 (very high)

Moss. Clin J Am Soc Nephrol. 3:1379-1384, 2008. Cohen. Clin J Am Soc Nephro5:72-79, 2010.Lok. J Am Soc Nephrol 17:3204-3212, 2006.

Presents to CKD Clinic with

eGFR 39 ml/min

After 7 months, lost to followup for 24 months;

eGFR still 39 ml/min

Stable AP; starts ESA and Fe therapy at

CKD Clinic; CKD options presented

AMI with pulmonary

edema; ER HD started via TCC

(AVF nonfx)

Recurrent AP and PTA; GI bleed; continues with

TCC

Now s/p AMI x 2 and PTA x 5; many

transfusions for MDS; eGFR 30

ml/min

HD chosen and AVF placed

TCC replaced x 3; AVF surgery deferred b/o CVDz; several transfusions

Jan 2011-June 2011May 2010-Dec 2010Jan 2010-April 2010May 2007-Dec 2009

Died at home

• Provide education earlier on and engage family in descriptions of options , risks and responsibilities of dialysis for patient and family.

• Present the ‘no dialysis’ option with objectivity and enthusiasm.• Present need for AVF, risk for FTM and prepare for AVF intervention requirements.• Consider AVG in cases of insistence or requests for time-limited trials.

Rationale for Considering the “No Dialysis” OptionSurvival continues to be poor for ESRD.Dialysis impacts quality of life on many levels.Life on dialysis entails burdens likely to detract

from quality of life.Likelihood of functional decline once starting

dialysis is high.Dialysis may not be the best form of therapy for

every patient.

.Holley. Adv Chronic Kidney Dis 14:316-318, 2007.Tamura. N Engl J Med 361:1539-1547, 2009.Weisbord. Adv Chronic Kidney Dis 14:316-318, 2007.

When Considering the “No Dialysis” Option…

A growing literature supports active non-dialytic (“conservative”) management for advanced CKD.

Active non-dialytic management may be appropriate for certain patients with a poor prognosis for survival.

Active non-dialytic management does not mean no management or no care.

Smith. Nephron Clinical Practice 95:C40-c46, 2003.Carson. Clin J Am Soc Nephrol 4: 1611-1619, 2009.Wong. Ren Fail 29:653-659, 2007.

Advance Care Planning for Patients with CKDMultiple comorbid conditions, effects of chronic illness add to

the complexities of ACP for CKD patients.Cognitive impairment common in older CKD patients.Preferences about dialysis may change over time and may be

influenced by:Functional statusDepressionCognitive ability to appreciate impact of disease on QOL Understanding of trappings associated with day-to-day

operations of dialysisPerceptions of the dying process (right or wrong) should dialysis

be foregone Fried. J Am Geriatr Soc 55:1007-1014, 2007.Hooper. MJA 165: 416-419. 1996.Murray. Neurology 67:216-223, 2006.

• Depression Assessment• Cognitive Capacity Assessment• Decision Making Capacity Assessment• Quality of Life and Functional Status Assessment• Prognosis Assessment• National Kidney Foundation Initiation and Withdrawal Checklists• Pain and Symptom Assessment and Management• Communication Skills• Glossary of Terms

RPA Clinical Practice Guideline in the Appropriate Initiation and Withdrawal from Dialysis, 2nd Edition,

2010.

Informed Consent for DialysisInitiation of dialysis presumes appropriate provision of

informed consentIdeally, begins as part of ACP long before decision

neededImportance underscored by high rates of withdrawal

from dialysisSecond to CVD as a cause of deathAccounts for 25% of dialysis patient deaths

Requires sufficient understanding and knowledge of one’s circumstances.

Informing Prospective Dialysis Patients about the Contingencies of their ConsentInformed consent for dialysis includes discussion of

options for permanent access.Requirements for permanent access warrant full

disclosure at the time of informed consent.Cost, pain and risk associated with surgical

intervention warrant consideration and disclosure.

Taking an Age-Attuned ApproachSpecific Issues to Discuss with Older CKD PatientsDialysis may not confer a survival advantage over

maximum medical management.Patients with significant level of illness are more

likely to die than live long enough to progress to ESRD.

Life on dialysis entails significant burdens that may detract from their quality of life.

It is likely that they may not experience any functional improvement with dialysis.Joly. J Am Soc Nephrol 14:1012-1021, 2003.

Eriksen. Kidney Int 69:375-382, 2006.Dalrymple. J Gen Intern Med 26:379-38, 2011.

El-Ghoul. JAGS 57: 2217-2223, 2009.Tamura. N Engl J Med 361:1539-1547, 2009.Weisbord. Adv Chronic Kidney Dis 14:316-318, 2007.

Taking an Age-Attuned ApproachSpecific Issues to Discuss with Older CKD PatientsThey may undergo significant functional decline during the

first year after dialysis initiation.Maximum medical management includes usual integrated

CKD care without dialysis and does NOT mean ‘no care’.Palliative care is available irrespective of their decision to

pursue or forego dialysis.Hospice is an appropriate consideration for patients with

additional terminal illness.

RPA Clinical Practice Guideline in the Appropriate Initiation and Withdrawal from Dialysis, 2nd Edition,

2010.

Recommendations for Providing Informed Consent to Older Patients Contemplating DialysisInitiate advanced care planning early on in the

continuum of CKD.Integrate informed consent as part of the deliberation

process when contemplating dialysis.Assure decision making capacity and cognitive capacity

for comprehension.Engage the patient’s family in the decision making

process.Present estimate of renal and overall prognosis with

and without dialysis.Determine and agree on the patient’s goals, for both

short-term and long-term care.Schmidt RJ. Clin J Am Soc Nephrol 7:185-191, 2012.

Recommendations for Providing Informed Consent to Older Patients Contemplating DialysisMake plans for dealing with symptoms that could occur

should renal failure progress faster than anticipated and/or faster than other co-morbid conditions.

Discuss desires for acute symptom management and goal to avoid “heat of the moment” decisions.

For those choosing dialysis, discuss modality and dialysis access options, and explain requirements and responsibilities associated with vascular access or peritoneal dialysis catheter placement.

Schmidt RJ. Clin J Am Soc Nephrol 7:185-191, 2012.

Approach to the Elderly Patient with ESRD

Berger J R , Hedayati S S CJASN 2012;7:1039-1046

©2012 by American Society of Nephrology

The model uses such factors as

cognitive impairment,

functional impairment,

and the severity of comorbid

conditions to help guide the clinical thought

process.

Guideline for Shared Decision Making – 2nd Edition

Endorsed by:Renal Physicians Association American Academy of Hospice and Palliative MedicineAmerican Academy of PediatricsAmerican Association of Critical Care NursesAmerican Association of Kidney PatientsAmerican College of Nurse PractitionersAmerican Geriatrics SocietyAmerican Society of Pediatric NephrologyCenter to Advance Palliative CareForum of End-Stage Renal Disease NetworksKidney End-of-Life CoalitionNational Hospice and Palliative Care OrganizationNational Renal Administrators AssociationSociety of Critical Care Medicine

Recommendations1. Develop a physician-patient relationship for shared decision

making.2. Fully inform acute kidney injury (AKI), stage 4 and 5 CKD, and

ESRD patients about their diagnosis, prognosis and all treatment options.

3. Give all patients with AKI, stage 5 CKD, or ESRD an estimate of prognosis specific to their overall condition.

4. Institute advanced care planning.5. If appropriate, forgo (withhold initiating or withdraw ongoing)

dialysis for patients with AKI, CKD, or ESRD in certain, well-define situations.

6. Consider forgoing dialysis for AKI, CKD, or ESRD patients who a very poor prognosis or for whom dialysis cannot be provided safely.

Recommendations, continued7. Consider a time-limited trial of dialysis for patients requiring

dialysis but who have an uncertain prognosis, or for whom a consensus cannot be reached about providing dialysis.

8. Establish a systematic due process approach for conflict resolution if there is disagreement about what decision should be made with regard to dialysis.

9. To improve patient-centered outcomes, offer palliative care services and interventions to all AKI, CKD, and ESRD patients who suffer from burdens of their disease.

10. Use a systematic approach to communicate about diagnosis, prognosis, treatment options, and goals of care.

Develop a physician-patient relationship for shared decision makingEnsures patients’ values and preferences play a

prominent roleAddresses ethical obligation to provide full disclosure of

risks and benefitsParticipants should include:

PatientsPhysicians Legal agent in case of loss of decision-making capacity

Fully inform acute kidney injury (AKI), stage 4 and 5 CKD, and ESRD patients about their diagnosis, prognosis and all treatment options

AKI patients: Decisions about acute RRTx should be made in context of

other life sustaining treatmentsCKD 4-5/ESRD patients:

In addition to dialysis, treatment options should include not starting dialysis and/or a time-limited trial of dialysis

Give all patients with AKI, stage 5 CKD, or ESRD an estimate of prognosis specific to their overall conditionCKD 5 patients:

The surprise question together with risk factors for poor prognosis (age, comorbidities, severe malnutrition, poor function status) to estimate prognosis

ESRD patients experiencing major complications:When major complications reduce QOL, it is appropriate to

reassess treatment goalsConsider withdrawal from dialysis

PrognosisEstimates should/will impact course of actionDated and documented discussions may facilitate

informed decision makingEstimates can be used to develop consensus on goals of

therapy and careEarly and continued discussion may facilitate

reassessment in the event of complications that reduce survival or quality of life

Institute advanced care planning

Help patients understand his/her condition.Prepare for decisions that may have to be made as the

condition progresses over time.

If appropriate, forgo (withhold initiating or withdraw ongoing) dialysis for patients with AKI, CKD, or ESRD in certain, well-define situations

Fully informed patients with DMC, who voluntarily refuse dialysis or request its discontinuation

Patients who no longer have DMC or who indicated refusal of dialysis in an advanced directive

Patients without DMC, whose properly appointed agent refuses dialysis or requests its discontinuation

Patients with irreversible, profound neurological impairment and lack signs of thought, sensation, purposeful behavior or awareness of self or environment

Consider forgoing dialysis for AKI, CKD, or ESRD patients who a very poor prognosis or for whom dialysis cannot be provided safely

Patients whose condition renders them unable to cooperate with the technical process of dialysis

Patients with terminal illness from non-renal causes (where no benefit from dialysis is anticipated)

Patients who meet two or more criteria for statistically significant poor prognosis.

Time-Limited TrialsConsider in patients:

requiring dialysis who have an uncertain prognosisfor whom a consensus cannot be reached about

providing dialysisAgree in advance on the length of the trial and

parameters to be assessed during and at the completion of the trial to determine whether dialysis has benefited the patient and whether it should be continued

Use a systematic approach to communicate about diagnosis, prognosis, treatment options, and goals of careGood communication improves patients’

adjustment to illness, increases adherence to treatment and results in higher patient and family satisfaction

Patients’ decisions should be based on an accurate understanding of their condition and the pros and cons of treatment options.

End of Life Care PreferencesSurvey of 584 Stage 4-5 CKD patients • EOL care needs not integrated into renal care.• Patients had poor knowledge of palliative care options

and illness trajectory.• Majority of patients wanted to die at home (36%) or in

inpatient hospice (29%).• Less than 10% had discussed EOL care with nephrologist.• Large number (61%) regretted decision to start dialysis!

Davison. Clin J Am Soc Nephrol 5:195-204,2010.

For most dialysis patients, the quality of their lives For most dialysis patients, the quality of their lives determines their acceptance or rejection of medical determines their acceptance or rejection of medical

interventions to prolong life. Because the quality of their interventions to prolong life. Because the quality of their lives changes, their goals for care and treatment change. lives changes, their goals for care and treatment change.

Thus, advance care planning is a dynamic process and Thus, advance care planning is a dynamic process and nota single event resulting from one conversation.nota single event resulting from one conversation.

Holley J L CJASN 2012;7:1033-1038

ConclusionsShared decision making processes are key to assuring the best

choice for a given patient.

Preparation includes education about modalities and the burdens inherent in their implementation.

Advance care planning is a process that must evolve with changes in a patient’s health care conditions in a changing health care environment.

Dialysis may not be the best option for all patients.

Older patients warrant an age-attuned approach.

HD MORTALITY PREDICTORProgrammed by Stephen Z. Fadem, M.D., FASN and Joseph Fadem

SERUM ALBUMIN g/dLSURPRISE QUESTION

I would NOT be surprised if my patient died in the next 6 months.

I would be surprised if my patient died in the next 6 months.AGE yearsDEMENTIA

My patient HAS dementia.My patient does NOT have dementia.

PERIPHERAL VASCULAR DISEASEMy patient HAS peripheral vascular disease.My patient does NOT have peripheral vascular disease.

XBETA: -154.59Predicted Six Month Survival: 89%Predicted Twelve Month Survival: 74%Predicted Eighteen Month Survival: 60%

ResourcesTOUCHCALC http://touchcalc.com

Charlson Comorbidity ScoreSurprise question – hemodialysis predictor scoreKarnofsky score

Clinical Practice Guideline in the Appropriate Initiation and Withdrawal from Dialysis, 2nd Edition, 2010

End of Life Coalition – ESRD Network 5http://www.kidneyeol.org/advanced.htm