Wednesday, July 11, 2012

Less is more: Nephrology point of view

To dialyze or not to dialyze is the question that we face sometimes in the elderly and AKI in severe sepsis or cancer with no chance of recovery. What is the evidence that dailysis is going to prolong life or give a quality of life in these individuals? Sometimes we feel that we have to offer something. Offering "no dialysis" should also be an option.  It all depends on the medical issues involved and overall prognosis, a combined team decision involving all members involved including patient or family might be needed. A recent CJASN attending rounds issue discusses the dialysis question in AKI with metastatic cancer with poor prognosis in the ICU.  Dr Moss takes the readers to a  7 step process of how to ethically make a decision that is optimal for patient care. The four topics that are extremely important are: Medical indications, patient preferences, quality of life and contextual features. Now, perhaps in some countries, economics might even play a larger role. A recent Newsweek article also shares a similar story of the costs involved in end of life care for a loved one in USA.
A shared decision making algorithm as proposed by Moss's article should be a must read for all.
Why is that nephrologist are not comfortable in not offering aggressive therapy? How do they compare to their counterparts in oncology, cardiology, and critical care?  Is it their medical school training, residency training or fellowship experiences? We must answer these questions to better improve training of nephrologist and make them better equipped to handle palliative decision making.  Please take our survey on this topic if you are a fellow in training. A similar survey being performed for program directors and fellows on hospice as well, please take that as well.

Other articles to consider for a read on this topic
http://www.ncbi.nlm.nih.gov/pubmed/21896833
http://www.ncbi.nlm.nih.gov/pubmed/21601331

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