The discussion about end-of-life care often centers around the value of invasive surgeries and that of palliative care, which is designed to treat symptoms rather than the cause of illness. One treatment that is rarely referred to as voluntary is kidney dialysis, which is defined by the National Kidney Foundation as treatment that includes the removal of waste, salt and extra water to prevent them from building up in the body; the maintenance of a safe level of potassium, sodium and bicarbonate in the blood; and control of blood pressure.
In 2016, more than 104,000 people over age 75 and over 130,000 patients aged 65 to 74 were receiving dialysis in the U.S., according to the United States Renal Data System. It is possible that many of these patients were never informed of other treatment options.
Researchers have reported that patients frequently report that they did not decide to do dialysis, with many explaining that they never even knew there was a choice. In a study conducted by Tufts University, in a small sample of nephrologists, only one-third regularly informed patients about the main non-dialysis treatment for kidney disease.
The non-invasive alternative to dialysis is referred to as “conservative management,” and it is meant to slow the disease’s progression and treat its symptoms and complications. Conservative management often consists of regulating diet, controlling blood pressure and hormone treatment, under the guidance of a physician.
Dialysis was developed to be a short-term treatment that would keep patients with kidney disease alive until they could receive transplants, but some patients are now on dialysis indefinitely.
While dialysis can prolong the lives of people with kidney disease, it can also be draining on patients. Dialysis treatment often requires traveling to a clinic multiple times a week for four-hour sessions or performing multiple fluid exchanges daily at home. Some experts argue that conservative management offers patients a less burdensome treatment option.
Some studies have shown that older patients being treated with dialysis survive longer than those using conservative management, but the benefit of dialysis all but disappears for patients over age 75. The authors of the study explained that the difference in prolonging survival is not as present for patients over 75 because they are often affected by other serious health problems.
With modern medical advances increasing lifespan, prolonging life is not the only thing patients value. Susan Wong, a nephrologist at the Veterans Affairs Health Services Research and Development Center in Seattle, explained why some conservative management may be a better option for some patients in an interview with the New York Times.
“Dialysis is a life-changing event... It’s a very demanding form of treatment. It involves medical issues, spiritual issues, quality of life. It’s a big decision,” Wong said.
Many individuals are choosing palliative care in order to avoid more intense treatment. Recent research has shown that at the end of their life, patients using conservative management were less likely to be hospitalized, to undergo aggressive procedures and to die in a hospital as compared to dialysis patients.
One of the main obstacles patients with kidney disease face when deciding on a course of treatment is their physicians. A study conducted in part by Wong of Veterans Affairs patients who declined dialysis found that doctors questioned their patients’ decision-making ability and pushed them to change their minds.
In the qualitative analysis of medical record notes for 851 patients with advanced kidney disease who decided not to undergo dialysis, it was found that physicians had difficulty accepting their patients’ wishes not to start dialysis, and practitioners seemed to believe that beyond dialysis, there was no option for treatment.
Conservative management remains an option for older patients with kidney disease and/or those who do not wish to undergo a kidney transplant.
Medical care is supposed to be centered around patients, and the state of treatment for kidney disease in the United States does not currently reflect this.
