ORLANDO, FL—Dialysis therapy may not be the approach of choice for all elderly patients with end-stage renal disease (ESRD), but working with patients and their families to determine the treatment route that best suits the individual patient's medical condition and personal preferences can be difficult.
“Most of us haven't received a lot of training in talking to patients about these issues, and I think in general, even for those who have received training, it can sometimes feel uncomfortable to bring up these end-of-life issues,” said Manjula Kurella Tamura, MD, MPH, who co-moderated a session on geriatric nephrology here at the National Kidney Foundation Spring Clinical Meetings.
“Absolutely it is challenging, but I think the information in the literature, at least in other end-of-life situations like patients with terminal cancer, terminal dementia, suggests that patients and families really want this information,” Dr. Kurella Tamura said in a phone interview after the meeting. “We are scared to deliver it, but the patients and families really benefit from getting this information.
“Our goal is not to force people to not choose dialysis, but to help them make decisions that are best for them, and getting prognostic information is always valuable, regardless of what type of therapy you choose.” Dr. Kurella Tamura is Assistant Professor of Medicine in the Division of Nephrology at Stanford University School of Medicine, and her research focuses on chronic kidney disease (CKD) management and outcomes in elderly patients.
One of the first steps to having a productive conversation about treatment options comes even before the nephrologist has ever seen the patient—early referral.
“It's really difficult to have a discussion about a subject like this the first time you meet a patient, and so if patients are referred earlier in the course of their disease, you're more likely to have an open and honest discussion later in the course when it's the right time,” Dr. Kurella Tamura said.
When an elderly patient with ESRD does present to the nephrologist, it's important to identify where in the disease trajectory that patient is, noted Mark Swidler, MD, of Mount Sinai Medical Center, in a presentation during the session. Dr. Swidler has expertise in geriatric nephrology and renal palliative care.
“As patients progress after a number of years on dialysis or after a number of acute hospitalizations, you can see that there's a very big possibility that the focus of dialysis will move from prolonging life, improving function, to more on the restorative symptom-control side,” Dr. Swidler said.
A geriatric assessment should be performed, he added. Such an assessment examines function, disabilities, and comorbidities, defining a patient's geriatric syndrome. Types of geriatric syndromes include frailty, dementia, delirium, depression, falls, malnutrition, and polypharmacy.
While chronological age is an important predictor of adverse outcomes in patients on dialysis, functional age is more informative for making a decision about therapy, Dr. Swidler said. One tool for assessing the likelihood of functional decline is the Vulnerable Elders Survey (VES-13), which asks patients about difficulty doing tasks like shopping for personal items, managing money, walking across a room, doing light housework, and bathing or showering.
Another simple test is to assess older patients for the frailty phenotype, he said. Fried and colleagues defined frailty as a clinical syndrome in which three or more of the following criteria are present—unintentional weight loss of 10 lbs in the past year, self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity (J Gerontol A Biol Sci Med Sci 2001; 56:M146-M157).
“This cycle of frailty continues to march, and eventually it leads to disability, dependency, nursing home, and death,” Dr. Swidler said. “I think we need to concentrate a lot more on this when we are looking at our patients than just looking at their comorbidities alone.”
Information gleaned from these assessments can then be incorporated into the four-category method Dr. Swidler uses when evaluating a patient for dialysis. The categories are: medical indications, patient preferences, quality of life, and contextual features.
Questions considered under the medical indication category are:
* What is the functional age of the patient, or is the patient healthy, vulnerable, or frail?
* What are the survival data?
* What are the geriatric susceptibility factors?
* Is the patient a nursing home patient, and are nursing home patients different?
* Based on the answers to the previous questions, is the patient a candidate for dialysis or non-dialysis medical therapy?
In terms of patient preferences, it is important to establish “big-picture goals,” Dr. Swidler said.
“This I think is really where palliative care intervention can help because we use a family-leading model where we try to talk about what is important to that person. How would they like to spend the next ‘x’ amount of years?”
Quality of life is a personal value judgment with no universal metric, but there are some objective criteria, such as end-stage dementia, cachexia, and advanced cancer, Dr. Swidler said. A time-limited trial of dialysis can shed light on whether or not quality of life would be acceptable for the particular patient.
In terms of contextual features, family support or lack of support for the patient's decision should be considered.
“We know that even if a patient is a suboptimal candidate for dialysis, some of these other things will trump that, especially patient preferences,” Dr. Swidler said.
Language Is Key
When talking with patients and families about whether to pursue dialysis or non-dialysis therapy, language is critical, Dr. Swidler noted.
“We're really getting away from talking about ‘to withdraw’ or ‘withhold’ and using terms like ‘to forego.’ ‘To forego’ really implies that the patient is exercising informed consent. We talk about ‘non-dialysis therapy’ instead of ‘conservative therapy,’ and, from a psychological point of view, this sends the message that they are getting another kind of therapy that is as good.”
Instead of being designated a “poor” candidate for dialysis, a patient should be described as a “suboptimal” or “non-ideal” candidate, Dr. Swidler said.
An environment of empathy should be created during these conversations, with open-ended questions asked and the responsibility for decision making shared, he added during an interview at the meeting.
“Probably the most important thing is not to go with an agenda. You go and you have facts—I presented a set of facts about some of the risk factors for poor outcome—and you go and you speak.
“I ask two questions: What is your understanding of your condition, and what is most important to you as you go forward? It's not, ‘Do you want dialysis or not?' It's really a more general question of what do you envision in the next years that come up for you. What are some of the things that you're trying to achieve, or what makes your day? When a person starts to speak in that way, then you can be a lot more helpful as to whether dialysis is appropriate or not, or whether it's going to improve something, or whether there's enough of a balance that they will commit to dialysis.”
‘Looking Beyond Organs'
But time and reimbursement pressures can be the enemy of performing a complete geriatric assessment, and getting a geriatric or palliative care consult can help.
“I'm not sure that nephrologists can necessarily do the geriatric palliative care parts within the current traditional templates that they have because they're just so busy with some of the very basic operations of the dialysis unit,” Dr. Swidler said in the interview. “However, I will say that they have a multidisciplinary team in place—they have a dietitian; they have a social worker; they have the nephrologist—and I think it would be not too much more—and again it's economy driven, unfortunately—to incorporate more of these geriatric components.”
A multidisciplinary team can see to the needs of the whole patient.
“The general message is looking beyond organs and looking at people and looking at the things that are most important to them, which in terms of quality of life are functional level and cognition,” Dr. Swidler said. “Those are the things that are the building blocks of independence and enjoyment in the later years, so I think we have to pay more attention to whatever it takes to optimize those things.”