Advertisement

Geriatric Nephrology and Urology

, Volume 2, Issue 2, pp 109–117 | Cite as

Withholding and withdrawing dialysis from elderly ESRD patients: Part 1—A historical view of the clinical experience

  • L.S. Rothenberg
Review article

Abstract

A review in Part 1 (utilizing US, Canadian and European sources) of the historical and current practices of using age as a selection criterion for dialysis patients demonstrates different national policies and practices. The medical and psychosocial data regarding elderly dialysis patients yield mixed conclusions, but suggest much more positive patient experiences than are generally acknowledged. Part 2 of this paper presents a range of ethical arguments about rationing dialysis therapy for the elderly as a matter of governmental or helath care system policy, based on various ethical principles and notions of “distributive justice.” The seeming greater ethical consensus for not using age per se as a criterion for individual treatment decisions is not reflected in current clinical practice. Finally, discontinuing dialysis has been supported on ethical grounds, and the overall practice of caring for elderly dialysis patients can be facilitated by careful decisionmaking procedures and the provision of appropriate emotional support for patients, families and caregivers, also discussed in Part 2.

Key words

ethics medical kidney failure chronic therapy hemodialysis attitude of health personnel health care rationing aged treatment refusal life support care 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Kane RL, Solomon DH, Beck JC et al. Geriatrics in the United States: Manpower Projections and Training Considerations. Lexington, MA: Heath; 1981.Google Scholar
  2. 2.
    Fox RC, Swazey JP. The courage to fail: a social view of organ transplants and dialysis. 2nd ed. rev. Chicago, IL: University of Chicago Press; 1978.Google Scholar
  3. 3.
    Katz AH, Proctor DM. Social-psychological characteristics of patients receiving hemodialysis treatment for chronic renal failure. Washington, DC: U.S. Public Health Service, Kidney Disease Control Program; 1969.Google Scholar
  4. 4.
    Kjellstrand CM LG. Racial, sexual and age inequalities in chronic dialysis [editorial]. Nephron 1987; 45: 257–63.Google Scholar
  5. 5.
    Moskop JC. The moral limits to Federal funding for kidney disease. Hastings Cent Rep 1987; 17: 11–5.Google Scholar
  6. 6.
    Fox RC. Exclusion from dialysis: a sociologic and legal perspective. Kidney Int 1981; 19: 739–51.Google Scholar
  7. 7.
    O'Brien ME, Donley R, Flaherty MJ, Johnstone B. Therapeutic options on end-stage renal disease: a preliminary report. ANNA J 1989; 13: 313–8.Google Scholar
  8. 8.
    U.S. Congress. Office of Technology Assessment. Life-sustaining technologies and the elderly. Washington, DC: U.S. Government Printing Office; 1987.Google Scholar
  9. 9.
    Plawecki HM, Brewer S, Plawecki JA. Chronic renal failure. J Gerontol Nurs 1987; 13: 14–7.Google Scholar
  10. 10.
    Husebye DG, Kjellstrand CM. Old patients and uremia: rates of acceptance to and withdrawal from dialysis. Int J Artif Organs 1987; 10: 166–72.Google Scholar
  11. 11.
    Cohen C. Ethical and legal considerations in the care of the infant with end-stage renal disease whose parents elect conservative therapy. Pediatr Nephrol 1987; 1: 166–71.Google Scholar
  12. 12.
    Prottas J, Segal M, Sapolsky HM. Cross-national differences in dialysis rates. Health Care Financing Rev. 1983; 4: 91–103.Google Scholar
  13. 13.
    Kjellstrand CM. Giving life - giving death: ethical problems of high-technology medicine. Acta Med Scand 1988; 725 [suppl]: 1–88.Google Scholar
  14. 14.
    Eggers PW. Health care policies/economics of the geriatric renal population. Am J Kidney Dis 1990; 16: 384–91.Google Scholar
  15. 15.
    Brown WW. Introduction. Am J Kidney Dis 1990;16: 273–4.Google Scholar
  16. 16.
    Andreu J, de la Torre M, Oppenheimer F, Campistol JM et al. Renal transplantation in elderly recipients. Transplant Proc 1992; 24: 120–1.Google Scholar
  17. 17.
    Kjellstrand CM. Age, sex, and race inequality in renal transplantation. Arch Intern Med 1988; 148: 1305–9.Google Scholar
  18. 18.
    Evans RW, Manninen DL, Garrison LPJ, Hart LG, Blagg CR, Gutman RA et al. The quality of life of patients with end-stage renal disease. N Engl J Med 1985; 312: 553–9.Google Scholar
  19. 19.
    Ingman SR, Gill D, Campbell J. ESRD and the elderly: cross-national perspective on distributive justice. In: Spicker SF, Ingman SR, Lawson IR, editors. Ethical dimensions of geriatric care. Dordrecht, The Netherlands; Kluwer Acad. Publ., 1987: 223–62.Google Scholar
  20. 20.
    Kjellstrand CM, Tyden G. Inequalities in chronic dialysis and transplantation in Sweden. Acta Med Scand 1988; 224:149–56.Google Scholar
  21. 21.
    Loew H. Die dauerdialysebehandlung im hoheren lebensalter (Long-term dialysis treatment in advanced age). Z Gerontol 1987; 20: 52–5.Google Scholar
  22. 22.
    Daniels N. Am I my parents' keeper? New York: Oxford University Press; 1988.Google Scholar
  23. 23.
    Aaron H, Schwartz W.The painful prescription. Washington, DC: The Brookings Institution; 1984.Google Scholar
  24. 24.
    Jennett B. High technology medicine and the elderly in Britain [editorial]. Int J Technology Assessment Health Care 1987; 3: 491–3.Google Scholar
  25. 25.
    Parsons V, Lock P. Triage and the patient with renal failure. J Med Ethics 1980; 6: 173–6.Google Scholar
  26. 26.
    Wing AJ. Why don't the British treat more patients with kidney failure? [editorial]. Brit Med J 1983; 287: 1157–8.Google Scholar
  27. 27.
    Deitch R. UK's poor record in treatment of renal failure. Lancet 1984; 2: 53.Google Scholar
  28. 28.
    Challah S, Wing AJ, Bauer R, Morris RW, Schreiber SA. Negative selection of patients for dialysis and transplantation in the United Kingdom. Br Med J 1984; 288: 1119–22.Google Scholar
  29. 29.
    Grimes DS. Rationing health care. Lancet 1987; 1: 615–6.Google Scholar
  30. 30.
    Who shall be dialysed? [editorial]. Lancet 1984; 1: 717.Google Scholar
  31. 31.
    Levine C. Stopping dialysis for “low quality” of life: a case from Britain [in brief]. Hastings Center Rep 1985; 15(1): 2–3.Google Scholar
  32. 32.
    Ward ED. Dialysis or death? Doctors should stop covering up for an inadequate health service. J Med Ethics 1986; 12: 61–3.Google Scholar
  33. 33.
    Ward E. Death or dialysis - a personal view [editorial]. Brit Med J 1984; 289: 1712–3.Google Scholar
  34. 34.
    Doyal L. General practice and the ethics of resource allocation. Practitioner 1987; 231: 1398–401.Google Scholar
  35. 35.
    Ethics and the nephrologist [editorial]. Lancet 1981; 1: 594–6.Google Scholar
  36. 36.
    Brahams D. End-stage renal failure: the doctor's duty and the patient's right. Lancet 1984; 2: 53.Google Scholar
  37. 37.
    McCarthy M. Treatment of end stage renal disease [letter]. Brit Med J 1984; 288: 1306–7.Google Scholar
  38. 38.
    Nicholls A, Feeest T. Treatment of end stage renal disease [letter]. Brit Med J 1984; 288: 1306–7.Google Scholar
  39. 39.
    Gabriel R. Ethics and the nephrologist [letter]. Lancet 1981; 1: 896.Google Scholar
  40. 40.
    Cameron JS, Challah S. Treatment of end stage renal failure and the aged in the United Kingdom, 1975–1984. Lancet 1986; 2: 962–6.Google Scholar
  41. 41.
    Halper T. End-stage renal failure and the aged in the United Kingdom. Int J Assessment Technology Health Care 1985; 1: 41–52.Google Scholar
  42. 42.
    Burton PR, Wallis J. Selection-adjusted comparison of life-expectancy of patients on continuous ambulatory peritoneal dialysis, haemodialysis, and renal transplantation. Lancet 1987; 1: 1115–8.Google Scholar
  43. 43.
    Horina JH, Holzer H, Reisinger EC, Krejs GJ, Neugebauer JS. Elderly patients and chronic haemodialysis [letter]. Lancet 1992; 339: 183.Google Scholar
  44. 44.
    Winearls CG, Oliver DO, Auer J. Age and dialysis [letter]. Lancet 1992; 339: 432.Google Scholar
  45. 45.
    Barnes JN, Johnson PT, Kent RE, Thacker J. Age and dialysis [letter]. Lancet 1992, 339: 432.Google Scholar
  46. 46.
    Krakauer H, Grauman JS, McMullan MR, Creede CC. The recent U.S. experience in the treatment of end-stage renal disease by dialysis and transplantation. N Engl J Med 1983; 308: 1558–63.Google Scholar
  47. 47.
    Held PJ, Pauly MV, Diamond L. Survival analysis of patients undergoing dialysis. JAMA 1987; 257: 645–50.Google Scholar
  48. 48.
    Long-term survival on dialysis. Lancet 1983; 2: 889–90.Google Scholar
  49. 49.
    Bihl MA, Ferrans CE, Powers MJ. Comparing stressors and quality of life of dialysis patients. ANNA J 1988; 15: 27–36.Google Scholar
  50. 50.
    Fuchs S, Schreiber M. Patients' perception of CAPD and hemodialysis stressors. ANNA J 1988; 145: 282–300.Google Scholar
  51. 51.
    Westlie L, Umen A, Nestrud S, Kjellstrand CM. Mortality, morbidity, and life satisfaction in the very old dialysis patient. Trans Am Soc Artif Organs 1984; 30: 21–30.Google Scholar
  52. 52.
    Auer J. Gokal R, Stout JP, Hillier VF et al. The Oxford-Manchester study of dialysis patients: age, risk factors and treatment method in relation to quality of life. Scand J Urol Nephrol 1992; 131 [Suppl]: 31–7.Google Scholar
  53. 53.
    Avram MR, Pena C, Burrell D, Antignani A, Avram MM. Hemodialysis and the elderly patient: potential advantages as to quality of life, urea generation, serum creatinine, and less interdialytic weight gain. Am J Kidney Dis 1990; 16: 342–5.Google Scholar
  54. 54.
    Nissenson AR, Diaz-Buxo JA, Adcock A, Nelms M. Peritioneal dialysis in the geriatric patient. Am J Kidney Dis 1990; 16: 335–8.Google Scholar

Copyright information

© Kluwer Academic Publishers 1992

Authors and Affiliations

  • L.S. Rothenberg
    • 1
  1. 1.Division of Medical Genetics, Department of MedicineUCLA School of MedicineLos AngelesUSA

Personalised recommendations