Choosing Death

Unravelling complex choices: multi-stakeholder perceptions on dialysis withdrawal and end-of-life care in kidney disease

BACKGROUND

For patients on dialysis with poor quality of life and prognosis, dialysis withdrawal and subsequent transition to palliative care is recommended. This study aims to understand multi-stakeholder perspectives regarding dialysis withdrawal and identify their information needs and support for decision-making regarding withdrawing from dialysis and end-of-life care.

METHODS

Participants were recruited through purposive sampling from eight dialysis centers and two public hospitals in Singapore. Semi-structured in-depth interviews were conducted with 10 patients on dialysis, 8 family caregivers, and 16 renal healthcare providers. They were held in-person at dialysis clinics with patients and caregivers, and virtually via video-conferencing with healthcare providers. Interviews were audio-recorded, transcribed, and thematically analyzed. The Ottawa Decision Support Framework's decisional-needs manual was used as a guide for data collection and analysis, with two independent team members coding the data.

RESULTS

Four themes reflecting perceptions and support for decision-making were identified: a) poor knowledge and fatalistic perceptions; b) inadequate resources and support for decision-making; c) complexity of decision-making, unclear timing, and unpreparedness; and d) internal emotions of decisional conflict and regret. Participants displayed limited awareness of dialysis withdrawal and palliative care, often perceiving dialysis withdrawal as medical abandonment. Patient preferences regarding decision-making ranged from autonomous control to physician or family-delegated choices. Cultural factors contributed to hesitancy and reluctance to discuss end-of-life matters, resulting in a lack of conversations between patients and providers, as well as between patients and their caregivers.

CONCLUSIONS

Decision-making for dialysis withdrawal is complicated, exacerbated by a lack of awareness and conversations on end-of-life care among patients, caregivers, and providers. These findings emphasize the need for a culturally-sensitive tool that informs and prepares patients and their caregivers to navigate decisions about dialysis withdrawal and the transition to palliative care. Such a tool could bridge information gaps and stimulate meaningful conversations, fostering informed and culturally aligned decisions during this critical juncture of care.

Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice

Dialysis withdrawal has become an accepted treatment option for patients with kidney failure and is one of the leading causes of death in patients receiving dialysis in high-income countries. Despite its increasing acceptance, dialysis withdrawal currently lacks a clear, consistent definition. The processes and outcomes of dialysis withdrawal have wide temporal and geographical variability, attributed to dialysis patient selection, influence from cultural, religious and spiritual beliefs, and availability of kidney replacement therapy and conservative kidney management. As a complex, evolving process, dialysis withdrawal poses an enormous challenge for clinicians and healthcare teams with various limitations precluding a peaceful and smooth transition between active dialysis and end-of-life care. In this review, we examine the current definitions of dialysis withdrawal, the temporal and geographical patterns of dialysis withdrawal, international barriers in the decision-making process (including dialysis withdrawal during the COVID-19 pandemic), and gaps in the current dialysis withdrawal recommendations for clinical consideration and future studies.

The role of depression symptoms in dialysis withdrawal

Among end-stage renal disease (ESRD) patients on hemodialysis, death from withdrawal from life-sustaining dialysis is increasingly common. The present study's objective was to examine depression as a potential risk factor for hemodialysis withdrawal. Two hundred forty ESRD hemodialysis (133 male and 107 female) patients were followed for an average of 4 years after depression symptom assessment. Of these, 18% withdrew from dialysis. Using multivariate survival analysis and after controlling for the effects of age (p < .001) and clinical variables, the authors found that level of depression symptoms was a unique and significant predictive risk factor for the subsequent decision to withdraw from dialysis (p < .05). The potential impact that depression may have on the decision to withdraw from hemodialysis should be considered by health care providers, patient families, and patients.

Renal dialysis abatement: lessons from a social study

AIM

This study aimed to examine the reasons why some people chose to abate (i.e., stop or not start) renal dialysis, together with the personal and social impact of this decision on the person concerned, and/or their families.

METHOD

A qualitative design based on the principles of Grounded Theory was employed. Semi-structured interviews were conducted with sixteen patients and/or carers (depending on whether the patient was able to be interviewed) where the issue of dialysis abatement was being considered, or had recently been decided.

RESULTS

Of 52 participants considered for entry into the study 41 were ineligible, with impaired cognition, rapid medical deterioration, and inability to speak sufficient English being the main reasons for exclusion. The desire not to burden others and the personal experience of a deteriorating quality of life were crucial elements in the decision to stop or decline dialysis. The problem of prognostic uncertainty and a sense of abandonment were also prominently expressed.

CONCLUSIONS

From this small Australian sample, it appears that there would be considerable potential benefit from a more proactive and open approach to end-of-life issues, with incorporation of the clinical and health promoting principles of palliative care into renal dialysis practice. The high number of exclusions shows how sick and unstable this population of patients is, but the issue of data gathering from people whose main language is not English requires attention.

The Renal Palliative Care Initiative

Despite ongoing technological advances, patients with end-stage renal disease (ESRD) have a mortality rate of approximately 23% per year, and comorbid cardiovascular, cerebrovascular, and peripheral vascular disorders often make life on dialysis an ordeal. This patient population needs an improved approach to symptom assessment and control, as well as advance care planning and high-quality palliative care. Families need support during the lifetime and after the death of their loved ones. To address these needs, the Renal Palliative Care Initiative (RPCI) was instituted at Baystate Medical Center, a large tertiary care hospital, and at eight dialysis clinics in the Connecticut River Valley. With the cooperation of a large nephrology practice, the Western New England Renal and Transplant Associates, a core group of physicians, nurses, and social workers were trained in palliative medicine, and charged with the goals of developing and implementing innovative interventions. The RPCI's programs include symptom management protocols, advance care planning, and bereavement services for families and staff. The Initiative is increasing completion of formal advance directives by the patient population, while staff and families are particularly pleased with annual renal memorial services. The RPCI experience has much to offer the practice of nephrology, and it is relevant to ongoing efforts to extend palliative medicine beyond the traditional focus on cancer and AIDS.

Quality end-of-life care in dialysis units

Quality end-of-life care has not been a priority in dialysis units and patients often experience prolonged dying while suffering needlessly. Advance directives (ADs) and decisions to stop dialysis have been highlighted by the medical profession as priorities in improving the quality of care, yet these are only two aspects of end-of-life care. They may not reflect patients' priorities and may not have the expected impact in improving the quality of end-of-life care. This review argues that quality end-of-life care should be a clinical priority in the care of dialysis patients; end-of-life care needs to be developed primarily from the patients' perspective; a clinical framework is required that integrates many aspects of end-of-life care; and end-of-life care should be initiated much earlier in the course of patients' illnesses than traditionally is done. By communicating more effectively and sooner with patients, their values and needs can be identified so we will be better able to plan and facilitate their end-of-life care and improve their experience of dying.

Dialysis discontinuation and palliative care

Little attention has been accorded to the terminal course and end-of-life care of patients after dialysis discontinuation. This prospective cohort observational study involves six dialysis clinics in the United States and two clinics in Canada. Data were collected on 131 patients who were undergoing maintenance dialysis and died after treatment discontinuation. Seventy-nine of the patients (60%) were prospectively studied until their deaths. Caregivers and families provided information about the symptoms and treatment provided in the final 24 hours of life, and structured interviews were conducted at the time of stopping dialysis with patients and families. The patient population was primarily white (73%), elderly (70 +/- 1.2 years), and diabetic (46%). Three quarters of the subjects had between three and seven comorbid conditions. Pain and agitation were the most common symptoms during the last day of life. Terminal treatment was generally considered to be satisfactory, and most people had good deaths. Although dialysis prolongs life, the integration of palliative medicine into dialysis programs offers opportunities to improve the quality of end-of-life care, especially for those patients who elect to stop treatment. Recommendations include making advance care planning an expectation at all clinics and using quality-of-dying measures to establish benchmarks for the provision of terminal care.

Withholding versus withdrawing life-sustaining treatment: patient factors and documentation associated with dialysis decisions

OBJECTIVE

We evaluated prospectively the use of acute hemodialysis among hospitalized patients to identify demographic and clinical predictors of and chart documentation concerning dialysis withheld and withdrawn.

DESIGN

Prospective cohort study.

SETTING

Five teaching hospitals.

PATIENTS

Five hundred sixty-five seriously ill hospitalized patients who had not previously undergone dialysis who developed renal failure.

MAIN OUTCOME MEASURES

Patient demographics, clinical characteristics, preferences, and prognostic estimates associated with having dialysis withheld rather than initiated and withdrawn rather than continued. Differences in chart documentation concerning decision-making for dialysis withheld, withdrawn, and continued.

RESULTS

Older patient age, cancer diagnosis, and male gender were associated with dialysis withheld rather than withdrawn. Age and gender differences persisted after adjustment for patients' aggressiveness of care preference. Worse 2-month prognosis was associated with both withholding and withdrawing dialysis. Chart documentation of decision-making was lacking more often for patients with dialysis withheld than for dialysis withdrawn.

CONCLUSIONS

Measuring the equity of life-sustaining treatment use will require evaluation of care withheld, not just care withdrawn. Older patients and men, after accounting for prognosis and function, are more likely to have dialysis withheld than withdrawn after a trial. Further exploration is needed into this disparity and the inadequate chart documentation for patients with dialysis withheld.

[Suicide and its psychopathological relations: a qualitative analysis of 6 cases of rational suicide]

We studied the meaning given to the terms "death" and "suicide" among psychiatric inpatients. Forty-four patients who had been admitted in a psychiatric inpatient unit following a suicide attempt underwent a qualitative interview, using a "general guide interview" approach. The results were analyzed systematically to investigate the relationship between attempted suicide and mental disorder. In 6 cases there was no correlation between the attempted suicide and psychopathological symptoms. One of these patients had a psychiatric diagnosis, but this did not seem to be related to the suicide attempt. All of them made a rational a deliberate suicidal act.

CONCLUSION

even in a psychiatric inpatient setting, suicide attempts are not always a behavioural expression of underlying psychopathological disturbances - individual and social factors also play a decisive role.

Denying the dying. Advance directives and dialysis discontinuation

A structured interview was administered to a sample of patients on maintenance dialysis and their attending physicians to obtain information on the documentation of their end-of-life treatment preferences. The majority of the patients reported never having considered stopping dialysis, or having discussed with their nephrologist or family the circumstances in which treatment should be discontinued. Only 7 patients (6%) had completed an advance directive; these patients were all men (P = 0.01) and tended to be better educated (P = 0.02). Only one of the nine physicians had completed an advance directive. In most cases, the dialysis patients and their treatment team staff were preoccupied with the struggles of daily life and had avoided or denied considerations of terminal illness and death. The literature on denial, medical illness, and dying is also reviewed as it relates to dialysis patients, end-of-life treatment, and terminal care.

Dysregulation of melatonin metabolism in chronic renal insufficiency: role of erythropoietin-deficiency anemia

Chronic renal failure (CRF) is associated with a variety of neurological and endocrine disorders. In this study, we examined the effect of CRF and the associated anemia on circadian variation of pineal hormone, melatonin. Animals were studied six weeks after 5/6 nephrectomy (CRF group, N = 26) or sham operation (control group, N = 28). A group of erythropoietin-treated CRF animals (CRF/EPO, N = 6) was included to discern the possible role of EPO-deficiency anemia. Compared with the normal control group, the CRF group showed a marked attenuation of the nocturnal surge in serum melatonin concentration. In addition, pineal gland melatonin content measured after a 12-hour dark cycle (< or = 2 lux) was significantly depressed in the CRF group when compared to that obtained in the control group. However, the CRF animals exhibited appropriate suppression of serum concentration and pineal tissue melatonin content in response to bright light (> or = 2500 lux). Administration of EPO led to correction of the CRF anemia and a marked improvement of the defective nocturnal rhythm of serum melatonin. Based on our results, experimental CRF is associated with a marked attenuation of the normal nocturnal surge of serum melatonin concentration. Regular EPO administration results in the correction of anemia and substantial reversal of this abnormality suggesting the partial role of EPO deficiency. The possible role of melatonin dysregulation in the pathophysiology of CRF and the potential value of melatonin supplementation in this condition is uncertain and awaits future investigations.

Psychiatric adjustment in end-stage renal disease: a follow up study of former paediatric patients

Life-time psychiatric adjustment was studied in forty-five young adult survivors of a paediatric dialysis and transplantation programme and in a comparison group matched for age and sex. Renal patients reported more psychological problems in childhood and had lower self-esteem in adulthood, but adult lifetime psychiatric morbidity was comparable in both groups. There were differences in the pattern of psychiatric disorder with a trend for more depressive states in the renal group. Lower self-esteem was linked to early onset renal disease and to educational and social dysfunction. Results indicate relatively favourable adult adjustment of juvenile renal patients.

Patient attitudes and psychological considerations in dialysis discontinuation

The authors surveyed 36 adult patients who were maintained with chronic renal dialysis concerning their attitudes about dialysis discontinuation. Few subjects reported having ever considered stopping the life-support treatment. When asked to consider 12 hypothetical scenarios in which they might consider stopping treatment (e.g., onset of dementia or blindness), most subjects would still not consider discontinuation. Consideration of dialysis discontinuation was directly correlated with the patient's educational level. Follow-up after 1 year underscored the substantial differences between the responses the subjects gave to the 12 hypothetical scenarios and their real-life responses when they were later faced with decisions to actually terminate treatment. Psychiatrists have an opportunity to participate in the complex clinical and ethical decisions associated with advance directives and patients' right to refuse life-support treatment.

Serum melatonin and 6-sulfatoxymelatonin in end-stage renal disease: effect of hemodialysis

The pineal hormone melatonin plays a role in the regulation of hypothalamic-pituitary axis, target gland function, sleep pattern, mood changes, cellular immunity, antibody response, and skin pigmentation, nearly all of which are also affected by renal insufficiency. We measured serum melatonin and its main urinary metabolite, 6-sulfatoxymelatonin (6-SM), by radioimmunoassay in 11 patients with end-stage renal disease (ESRD) between the hours of 6 and 9 a.m. during hemodialysis and again on an off-dialysis day. The results were compared with those obtained in a group of normal control subjects. Predialysis serum melatonin and 6-SM levels obtained at 6 a.m. in the ESRD patients were comparable with those obtained in the normal control group. Serum melatonin concentration in the ESRD group fell approximately 25% during dialysis while 6-SM remained virtually unchanged. The changes observed on the off-dialysis day during the same time period were of nearly the same magnitude as those seen during dialysis (-32% and 1.4%, respectively). No significant difference was found in the concentration of either analyte in the blood entering and leaving the dialyzer. These observations suggest a lack of discernible removal of either compound by hemodialysis. In contrast to the ESRD patients, who showed a slow fall in serum melatonin and no significant change in serum 6-SM on both on- and off-dialysis days, the normal control subjects showed an expected reduction in serum melatonin (-43%) and a sharp fall in serum 6-SM (-53%) between 6 and 9 a.m.(ABSTRACT TRUNCATED AT 250 WORDS)