1
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Butler CR, Wightman AG. Beyond Autonomy: Ethics of Decision Making About Treatments for Kidney Failure at the Extremes of Age. Am J Kidney Dis 2023; 82:360-367. [PMID: 37028637 PMCID: PMC10524142 DOI: 10.1053/j.ajkd.2023.01.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/18/2023] [Indexed: 04/08/2023]
Abstract
Decisions around initiating and forgoing treatments for kidney failure are complex, and contemporary approaches to medical decision making are designed to uphold patients' own preferences and values when there are multiple clinically reasonable treatment options. When patients do not have cognitive capacity to make their own decisions, these models can be adapted to support the previously expressed preferences of older adults and to promote open futures as autonomous persons for young children. Nonetheless, an autonomy-focused approach to decision making may not align with other overlapping values and needs of these groups. Dialysis profoundly shapes life experience. Values framing decisions about this treatment extend beyond independence and self-determination and vary between life stages. Patients at the extremes of age may place a strong emphasis on dignity, caring, nurturing, and joy. Models of decision making tailored to support an autonomous individual may also discount the role of family as not only surrogate decision makers but stakeholders whose lives and experience are interwoven with a patient's and will be shaped by their treatment decisions. These considerations underline a need to more flexibly incorporate a diversity of ethical frameworks to support medical decisions, especially for the very young and old, when facing complex medical decisions such as initiating or forgoing treatments for kidney failure.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, and the Kidney Research Institute, School of Medicine, University of Washington, Seattle; Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle.
| | - Aaron G Wightman
- Department of Pediatrics, School of Medicine, University of Washington, Seattle; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington
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2
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Zhong Y, Cavolo A, Labarque V, Gastmans C. Physician decision-making process about withholding/withdrawing life-sustaining treatments in paediatric patients: a systematic review of qualitative evidence. BMC Palliat Care 2022; 21:113. [PMID: 35751075 PMCID: PMC9229823 DOI: 10.1186/s12904-022-01003-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background With paediatric patients, deciding whether to withhold/withdraw life-sustaining treatments (LST) at the end of life is difficult and ethically sensitive. Little is understood about how and why physicians decide on withholding/withdrawing LST at the end of life in paediatric patients. In this study, we aimed to synthesise results from the literature on physicians’ perceptions about decision-making when dealing with withholding/withdrawing life-sustaining treatments in paediatric patients. Methods We conducted a systematic review of empirical qualitative studies. Five electronic databases (Pubmed, Cinahl®, Embase®, Scopus®, Web of Science™) were exhaustively searched in order to identify articles published in English from inception through March 17, 2021. Analysis and synthesis were guided by the Qualitative Analysis Guide of Leuven. Results Thirty publications met our criteria and were included for analysis. Overall, we found that physicians agreed to involve parents, and to a lesser extent, children in the decision-making process about withholding/withdrawing LST. Our analysis to identify conceptual schemes revealed that physicians divided their decision-making into three stages: (1) early preparation via advance care planning, (2) information giving and receiving, and (3) arriving at the final decision. Physicians considered advocating for the best interests of the child and of the parents as their major focus. We also identified moderating factors of decision-making, such as facilitators and barriers, specifically those related to physicians and parents that influenced physicians’ decision-making. Conclusions By focusing on stakeholders, structure of the decision-making process, ethical values, and influencing factors, our analysis showed that physicians generally agreed to share the decision-making with parents and the child, especially for adolescents. Further research is required to better understand how to minimise the negative impact of barriers on the decision-making process (e.g., difficult involvement of children, lack of paediatric palliative care expertise, conflict with parents). Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01003-5.
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Affiliation(s)
- Yajing Zhong
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, block D, box 7001, 3000, Leuven, Belgium.
| | - Alice Cavolo
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, block D, box 7001, 3000, Leuven, Belgium
| | - Veerle Labarque
- Centre for Molecular and Vascular Biology, Faculty of Medicine, KU Leuven/UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, block D, box 7001, 3000, Leuven, Belgium
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3
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Martin DE, Harris DCH, Jha V, Segantini L, Demme RA, Le TH, McCann L, Sands JM, Vong G, Wolpe PR, Fontana M, London GM, Vanderhaegen B, Vanholder R. Ethical challenges in nephrology: a call for action. Nat Rev Nephrol 2020; 16:603-613. [PMID: 32587403 DOI: 10.1038/s41581-020-0295-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2020] [Indexed: 12/14/2022]
Abstract
The American Society of Nephrology, the European Renal Association-European Dialysis and Transplant Association and the International Society of Nephrology Joint Working Group on Ethical Issues in Nephrology have identified ten broad areas of ethical concern as priority challenges that require collaborative action. Here, we describe these challenges - equity in access to kidney failure care, avoiding futile dialysis, reducing dialysis costs, shared decision-making in kidney failure care, living donor risk evaluation and decision-making, priority setting in kidney disease prevention and care, the ethical implications of genetic kidney diseases, responsible advocacy for kidney health and management of conflicts of interest - with the aim of highlighting the need for ethical analysis of specific issues, as well as for the development of tools and training to support clinicians who treat patients with kidney disease in practising ethically and contributing to ethical policy-making.
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Affiliation(s)
- Dominique E Martin
- School of Medicine, Deakin University, Geelong Waurn Ponds Campus, Geelong, VIC, Australia.
| | - David C H Harris
- University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- University of Oxford, Oxford, UK
- Manipal Academy of Higher Education, Manipal, India
| | - Luca Segantini
- International Society of Nephrology, Brussels, Belgium
- European Society for Organ Transplantation - ESOT c/o ESOT, Padova, Italy
| | - Richard A Demme
- Renal Division and Department of Medical Humanities and Bioethics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Thu H Le
- Nephrology Division, Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Laura McCann
- American Society of Nephrology, Washington, DC, USA
| | - Jeff M Sands
- Renal Division, Emory University School of Medicine, Atlanta, GA, USA
| | - Gerard Vong
- Center for Ethics, Emory University, Atlanta, GA, USA
| | | | - Monica Fontana
- European Renal Association - European Dialysis and Transplant Association, Parma, Italy
| | - Gerard M London
- Manhes Hospital, Nephrology Department GEPIR, Fleury-Mérogis, France
| | | | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine and Pediatrics, University Hospital, Corneel Heymanslaan 10, B9000, Gent, Belgium
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4
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Wightman A. Caregiver burden in pediatric dialysis. Pediatr Nephrol 2020; 35:1575-1583. [PMID: 31435726 DOI: 10.1007/s00467-019-04332-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/08/2019] [Accepted: 08/06/2019] [Indexed: 12/28/2022]
Abstract
In spite of improvements in expected survival, neurodevelopmental outcome, and quality of life, decision-making in neonatal dialysis remains controversial in high-resource countries. In part, this may be based upon the significant burdens experienced by the child, and also those experienced by the parents as caregivers. Emerging research offers a clearer description of the burdens experienced by dialysis caregivers worldwide. Caregiver burden represents an important area for nephrologists to advocate for patients and their families; however, nephrologists must also recognize the realities caregivers currently experience. Incorporation of caregiver burden into medical decision-making for children with end-stage kidney disease is necessary, but raises several ethical concerns.
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Affiliation(s)
- Aaron Wightman
- Divisions of Nephrology, Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA. .,Division of Nephrology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98115, USA. .,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA, USA.
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5
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Thumfart J, Bethe D, Wagner S, Pommer W, Rheinländer C, Müller D. A survey demonstrates limited palliative care structures in paediatric nephrology from the perspective of a multidisciplinary healthcare team. Acta Paediatr 2019; 108:1350-1356. [PMID: 30536480 DOI: 10.1111/apa.14688] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 12/02/2018] [Accepted: 12/05/2018] [Indexed: 12/14/2022]
Abstract
AIM Children and adolescents with end-stage renal disease face a high morbidity and mortality. Palliative care provides a multidisciplinary approach to reduce disease burden and improve quality of life. This study evaluated concepts and current structures of palliative care from the perspective of a multidisciplinary paediatric nephrology team including physicians, nurses and psychosocial health professionals. METHODS Evaluation was done by an online survey sent to the members of the German Society of Nephrology and to the nurse managers of German paediatric dialysis centres between April 9, 2018 and May 31, 2018. RESULTS Out of the 52 respondents, 54% were physicians, 21% nurses and 25% psychosocial health professionals. The quality of actual palliative care service was rated as moderate (3.3 on a scale from one to six). Specialised palliative care teams (54%) and the caring paediatric nephrologist (50%) were considered as primarily responsible for palliative care. Two thirds wished for training in palliative care. In only 15% of the respondents' centres, palliative care specialisation existed. CONCLUSION Palliative care structures in paediatric nephrology were not sufficient in the view of the multidisciplinary healthcare team. Therefore, efforts should be taken to integrate palliative care into the routine treatment of children and adolescents with chronic kidney diseases.
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Affiliation(s)
- Julia Thumfart
- Department of Paediatric Gastroenterology, Nephrology and Metabolic Diseases Charité–Universitätsmedizin Berlin Berlin Germany
| | - Dirk Bethe
- Division of Paediatric Nephrology Centre for Child and Adolescent Medicine Heidelberg University Hospital Heidelberg Germany
| | | | - Wolfgang Pommer
- Kuratorium für Dialyse und Nierentransplantation (KfH) Neu‐Isenburg Germany
| | | | - Dominik Müller
- Department of Paediatric Gastroenterology, Nephrology and Metabolic Diseases Charité–Universitätsmedizin Berlin Berlin Germany
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6
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Wightman A, Zimmerman CT, Neul S, Lepere K, Cedars K, Opel D. Caregiver Experience in Pediatric Dialysis. Pediatrics 2019; 143:peds.2018-2102. [PMID: 30696758 DOI: 10.1542/peds.2018-2102] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric dialysis is thought to be burdensome on caregivers given their need to assume dual responsibilities of parental and medical management of their child's chronic illness. In this study, we seek to describe the experience of parental caregivers of children receiving chronic dialysis for end-stage kidney disease. METHODS We performed semistructured interviews of primary caregivers of children with end-stage kidney disease receiving chronic peritoneal dialysis or hemodialysis for at least 8 weeks from March 2016 to April 2017 at 3 pediatric dialysis centers in the United States. We performed a thematic analysis to inductively derive and identify themes and subthemes related to positive and negative caregiver experiences. RESULTS Thirty-five caregivers completed interviews. Four major themes were identified, each with several subthemes: (1) caregiver medicalization (subthemes: diagnosis and initiation, disease management, and the future), (2) emotional adjustment (initial and/or acute phase, acceptance, personal growth, and medical stress and psychological burden), (3) pragmatic adaptation (disruption, adaptation of life goals and/or sense of self, and financial impact), and (4) social adjustment (relationship opportunity, relationship risk, advocacy, family functioning, and intimate relationships). These themes and subthemes reflected a broad range of experiences from positive to severely burdensome. CONCLUSIONS Caregivers of patients on dialysis report a broad range of positive and burdensome experiences. These results reveal a need for continued advocacy to support families with a child on dialysis and can be used to develop targeted measures to study and improve caregiver experience in this population.
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Affiliation(s)
- Aaron Wightman
- Divisions of Nephrology, .,Bioethics and Palliative Care, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
| | - Cortney Taylor Zimmerman
- Section of Psychology, Nephrology Service, Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Shari Neul
- Division of Hematology and Oncology, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee; and
| | - Katherine Lepere
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
| | - KristiLynn Cedars
- Division of Psychology, Department of Psychiatry and Behavioral Medicine, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Douglas Opel
- Bioethics and Palliative Care, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
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7
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Wightman A, Goldberg A, Diekema D. Fairness, severe intellectual disability, and the special case of transplantation. Pediatr Transplant 2018; 22:e13228. [PMID: 29785805 DOI: 10.1111/petr.13228] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2018] [Indexed: 11/27/2022]
Abstract
Children with severe intellectual disability have historically been excluded from solid organ transplantation. The purpose of this article was to review the arguments for excluding this population, including claims of poorer recipient and graft survival, a lower QoL as pediatric recipients become adults, and poorer outcomes for other, more deserving pediatric transplant candidates, and make the case that these arguments are no longer persuasive. We will argue that pediatric transplant centers for reasons of social justice, value of relationships, power differential, and fairness should generally not consider intellectual ability or disability as a criterion when making decisions regarding organ transplant eligibility.
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Affiliation(s)
- Aaron Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, WA, USA
| | - Aviva Goldberg
- Department of Pediatrics, University of Manitoba College of Medicine, Winnipeg, MB, Canada
| | - Douglas Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, WA, USA
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8
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Thumfart J, Reindl T, Rheinlaender C, Müller D. Supportive palliative care should be integrated into routine care for paediatric patients with life-limiting kidney disease. Acta Paediatr 2018; 107:403-407. [PMID: 29220099 DOI: 10.1111/apa.14182] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 11/13/2017] [Accepted: 12/05/2017] [Indexed: 11/26/2022]
Abstract
Paediatric palliative care is no longer restricted to patients with cancer and has been extended to patients with other chronic conditions, such as cystic fibrosis or neuromuscular disorders. This review focused on the current state of palliative care for children and adolescents with chronic kidney disease (CKD). We assessed the literature on CKD published up to August 2017. All the papers, except one from 1996, were published this century. This review discusses the role that palliative care plays in the process of decision-making and explores the possibilities of implementing palliative care into the routine therapy of affected patients and providing support for their families. Offering early palliative care as an integral part of the kidney, supportive care provided by the nephrology care team is both necessary and feasible for patients with CKD. As a minimum, a specialised palliative care team should be involved in patients with multiple comorbidities, in conservative treatment scenarios and in acute life-threatening complications. Further studies and guidelines are required to improve the care of patients with CKD and their families. CONCLUSION Supportive palliative care should be implemented into the routine care of patients with life-limiting kidney disease.
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Affiliation(s)
- Julia Thumfart
- Department of Pediatric Nephrology; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - Tobias Reindl
- Department of Oncology and Hematology; Charité - Universitätsmedizin Berlin; Berlin Germany
- Palliative Care Team; Björn-Schulz-Stiftung; Berlin Germany
| | | | - Dominik Müller
- Department of Pediatric Nephrology; Charité - Universitätsmedizin Berlin; Berlin Germany
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9
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Wightman A. Management dilemmas in pediatric nephrology: time-limited trials of dialysis therapy. Pediatr Nephrol 2017; 32:615-620. [PMID: 27942955 DOI: 10.1007/s00467-016-3545-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/24/2016] [Accepted: 10/26/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Time-limited trials of dialysis have been proposed as a third option in addition to initiation of treatment and comfort-care only in the setting of high uncertainty or discordance between the treating team and child/family or among the treating team. CASE-DIAGNOSIS/TREATMENT The index case was noted antenatally to have severe kidney disease and pulmonary hypoplasia. In light of the guarded, but uncertain prognosis and a lack of consensus among the treating team, as well as between the treating team and the family, a time-limited trial of dialysis was initiated. Six days later the child developed bacteremia due to infection of the dialysis catheter. The treating team felt this was a failure of the trial and that future dialysis should be withheld, the family disagreed. CONCLUSION A time-limited trial is a problematic option. Providers may be better suited by returning to the dichotomous choice of withholding or initiating treatment. KEY MANAGEMENT POINTS • Time-limited trials offer potential benefits in terms of alleviating the burden of decision-making in the setting of uncertainty, offering an opportunity to forecast a poor prognosis, help avoid interprofessional conflict, and providing support for patients, their families, and staff. • Time-limited trials have important limitations, including the use of time limits, difficulty in determining clear, meaningful endpoints, and different interpretations of a trial of therapy between parents and providers. • Decisions regarding the initiation, withholding, and withdrawal of dialysis should be made based on regular assessments of the benefits and burdens of the intervention for the child. • Pediatric nephrologists are better served to abandon the concept of time-limited trials.
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Affiliation(s)
- Aaron Wightman
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
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10
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Sakai T, Murakami Y, Okuda Y, Hamada R, Hamasaki Y, Ishikura K, Hataya H, Honda M. Prolonged respiratory disorder predicts adverse prognosis in infants with end-stage kidney disease. Pediatr Nephrol 2016; 31:2127-36. [PMID: 27271033 DOI: 10.1007/s00467-016-3430-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 04/27/2016] [Accepted: 05/16/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Among comorbidities, pulmonary hypoplasia (PH) is known as a significant risk factor for mortality in infants with end-stage kidney disease (ESKD). However, the final outcomes of infants with both ESKD and PH are still not well defined, as the diagnosis modality, and definition of PH severity remain ambiguous. METHODS Children initiating peritoneal dialysis during infancy from 1990 to 2015 were followed until death, date of last contact, or the end of 2015. We examined the long-term outcome of children with congenital pulmonary disorders by studying infants with prolonged respiratory disorders of greater than 28 days duration after birth and evaluated risk factors for mortality. RESULTS Forty-six children were followed (median follow-up, 9.23 years), and classified as children without (n = 38; Group A) or with (n = 8; Group B) a prolonged respiratory disorder. Overall actuarial 5 year survival rate in this cohort was 79.5 %. The survival curve in Group B showed a significant decline compared with Group A. Prolonged respiratory disorder was significantly associated with mortality by multivariate analysis (hazard ratio, 8.32). CONCLUSIONS Infants who initiate peritoneal dialysis complicated by prolonged respiratory disorders have increased adverse risk factors for mortality; therefore, withholding aggressive treatment should be considered.
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Affiliation(s)
- Tomoyuki Sakai
- Department of Pediatrics, Shiga University of Medical Science, Tsukinowa, Seta, Otsu, Shiga, 520-2192, Japan.
| | - Yoshitaka Murakami
- Department of Medical Statistics, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yusuke Okuda
- Department of Pediatrics, Shiga University of Medical Science, Tsukinowa, Seta, Otsu, Shiga, 520-2192, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yuko Hamasaki
- Department of Pediatric Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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11
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Wightman AG, Freeman MA. Update on Ethical Issues in Pediatric Dialysis: Has Pediatric Dialysis Become Morally Obligatory? Clin J Am Soc Nephrol 2016; 11:1456-1462. [PMID: 27037272 PMCID: PMC4974893 DOI: 10.2215/cjn.12741215] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Improvements in pediatric dialysis over the past 50 years have made the decision to proceed with dialysis straightforward for the majority of pediatric patients. For certain groups, however, such as children with multiple comorbid conditions, children and families with few social and economic resources, and neonates and infants, the decision of whether to proceed with dialysis remains much more controversial. In this review, we will examine the best available data regarding the outcomes of dialysis in these populations and analyze the important ethical considerations that should guide decisions regarding dialysis for these patients. We conclude that providers must continue to follow a nuanced and individualized approach in decision making for each child and to recognize that, regardless of the decision reached about dialysis, there is a continued duty to care for patients and families to maximize the remaining quality of their lives.
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Affiliation(s)
- Aaron G Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington; and
| | - Michael A Freeman
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
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12
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Sustaining life or prolonging dying? Appropriate choice of conservative care for children in end-stage renal disease: an ethical framework. Pediatr Nephrol 2015; 30:1761-9. [PMID: 25330877 DOI: 10.1007/s00467-014-2977-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/22/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
Abstract
Due to technological advances, an increasing number of infants and children are surviving with multi-organ system dysfunction, and some are reaching end-stage renal disease (ESRD). Many have quite limited life expectancies and may not be eligible for kidney transplantation but families request dialysis as alternative. In developed countries where resources are available there is often uncertainty by the medical team as to what should be done. After encountering several of these scenarios, we developed an ethical decision-making framework for the appropriate choice of conservative care or renal replacement therapy in infants and children with ESRD. The framework is a practical tool to help determine if the burdens of dialysis would outweigh the benefits for a particular patient and family. It is based on the four topics approach of medical considerations, quality-of-life determinants, patient and family preferences and contextual features tailored to pediatric ESRD. In this article we discuss the basis of the criteria, provide a practical framework to guide these difficult conversations, and illustrate use of the framework with a case example. While further research is needed, through this approach we hope to reduce the moral distress of care providers and staff as well as potential conflict with the family in these complex decision-making situations.
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13
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Survival and clinical outcomes of children starting renal replacement therapy in the neonatal period. Kidney Int 2014; 86:168-74. [DOI: 10.1038/ki.2013.561] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 11/20/2013] [Accepted: 11/21/2013] [Indexed: 01/06/2023]
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14
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Lantos JD, Warady BA. The evolving ethics of infant dialysis. Pediatr Nephrol 2013; 28:1943-7. [PMID: 23131864 PMCID: PMC3626731 DOI: 10.1007/s00467-012-2351-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/02/2012] [Accepted: 10/03/2012] [Indexed: 11/28/2022]
Abstract
In this paper, we review ethical issues that arise when families and doctors face clinical decisions about renal replacement therapy for an infant with end-stage renal disease (ESRD). Over the last 20 years, many centers have begun to routinely offer renal replacement therapy. However, doctors and nurses both continue to view such therapy as optional, rather than mandatory. We speculate that the burdens of therapy on the family, and the uncertainties about satisfactory outcomes have led to a situation in which renal replacement therapy remains desirable, but non-obligatory. We discuss the reasons why this is likely to remain so, and the ways in which renal replacement therapy for infants with ESRD is similar to, or different from, other clinical situations in pediatrics. Finally, we propose a research agenda to answer questions that are crucial to making good ethical decisions about infant dialysis.
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Affiliation(s)
- John D Lantos
- Children's Mercy Hospital, University of Missouri, 2401 Gillham Road, Kansas City, MO 64108, USA.
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15
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Teh JC, Frieling ML, Sienna JL, Geary DF. Attitudes of Caregivers to Management of End-Stage Renal Disease in Infants. Perit Dial Int 2011; 31:459-65. [PMID: 21454396 DOI: 10.3747/pdi.2009.00265] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives To characterize the attitudes of pediatric nephrologists caring for infants with end-stage renal disease (ESRD) compared with attitudes from a survey published in 1998. Nephrology nurses and social workers were included. Methods An e-mail survey was distributed to pediatric nephrology teams in Canada, Germany, Japan, the United Kingdom, and the United States. Results Survey responders totaled 270. Renal replacement therapy (RRT) is offered by all nephrologists to some children 1 – 12 months, and by 98% to some less than 1 month of age (93% in 1998). Of responding nephrologists, 30% offer RRT to all children less than 1 month of age (41% in 1998), and 50%, to all children 1 – 12 months. Among respondents, 50% indicated that parents can never refuse RRT for children aged 1 – 12 months, compared with 27% for younger infants. The most influential factor in rejecting RRT for infants was the presence of a co-existing abnormality. Nurses were more likely to believe that parents have the right to refuse RRT for infants. Conclusions Attitudes of pediatric nephrologists have changed since 1998. Also, nurses have opinions that are different from those of the nephrologists on some issues, and a consensus should be reached before speaking to families.
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Affiliation(s)
- Jun Chuan Teh
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Michelle L. Frieling
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Julianna L. Sienna
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Denis F. Geary
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Fauriel I, Moutel G, Duchange N, Montuclard L, Moutard ML, Cochat P, Hervé C. Decision making concerning life-sustaining treatment in paediatric nephrology: professionals' experiences and values. Nephrol Dial Transplant 2005; 20:2746-50. [PMID: 16204280 PMCID: PMC1910593 DOI: 10.1093/ndt/gfi160] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In a previous article, we studied decisions to withhold or withdraw life-sustaining treatment (LST) taken between 1995 and 2001 in 31 French-speaking paediatric nephrology centres. Files were available for 18 of the 31 centres. A grid was used to analyse the criteria on which decisions were based, and the results were enriched by an analysis of interviews with the doctors at these centres (31 interviews with doctors from the 18 centres). The goal was to describe in detail and to specify the criteria on which decisions to withhold or withdraw LST were based, in cases extracted from the files. The second paper deals exclusively with the interviews with doctors and analyses their lifetime's experience and perception. METHODS We carried out semi-directed interviews with nephrologists from all the paediatric nephrology centres in France and the French-speaking regions of Switzerland and Belgium. RESULTS We interviewed 46 paediatric nephrologists. Most were aware that decisions relating to LST are necessary and based on the assessment of the child's quality of life. According to them, decisions are not based on scientific criteria, but on the capacity to accept handicap, the family's past experiences and the doctor's own projections. They report that their task is particularly difficult when their action may contribute to death (withdrawal of treatment or acceleration of the process). They feel that their duty is to help the families in the acceptance of the doctors' decision rather than to encourage their participation in the decision-making process (DMP). CONCLUSIONS This article shows that paediatric nephrologists differ in their opinions, mostly due to their own ethical convictions. This observation highlights the need to establish common rules taking into account the views held by doctors. This is the only way to establish an ethical code shared by professionals.
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Affiliation(s)
- Isabelle Fauriel
- Laboratoire d'Ethique médicale et de Médecine Légale, Faculté de médecine de Paris 5, 45 rue des Saints Pères, 75006 Paris, France.
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Broyer M. Le pédiatre face à la fin de vie d'enfants hospitalisés en service de réanimation. Arch Pediatr 2005; 12:1445-7. [PMID: 16125919 DOI: 10.1016/j.arcped.2005.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2005] [Accepted: 07/04/2005] [Indexed: 11/16/2022]
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