Pulse
Reframing a Conversation
Nephrologists rethink how to talk to older, sicker patients about dialysis.
By Carmen Peota
The patient was 88 years old, had had several strokes, and suffered from dementia when her renal failure reached the end stage. Her nephrologist, Jeffrey Connaire, M.D., recalls telling the woman’s adult daughter, who was in charge of her care, that he doubted whether she would do well on dialysis and recommending medication to manage her symptoms as best as possible. The daughter agreed that medical management without dialysis was the better option. That might have been the end of the discussion, but extended family members questioned whether the woman was being offered less-than-optimal care because she was Native American. Connaire found himself involved in ongoing discussions as the family worked through their options.
Connaire, a nephrologist at Hennepin County Medical Center, shares the story as an example of how the decision about whether an elderly person with renal failure should go on dialysis is rarely straightforward. “It always strikes me in these situations that it’s easy for someone on a podium to say we shouldn’t offer dialysis for 88-year-olds or whatever,” he says. “But in reality, you have to treat everybody as an individual and respect their feelings, culture, and social background because in the end, everybody involved has to be comfortable with that decision.”
Connaire says he often finds himself having multiple meetings with patients and family members to explain that dialysis may or may not prolong the patient’s life and may or may not help them feel better. “I’m happy to do that,” he says, “but it’s a lot of effort.”
Having a discussion with older patients about whether they should go on dialysis is something he and other nephrologists are doing a lot these days. And, Connaire says, the conversation is often a difficult one.
The Disconnect
That’s largely because there is a mismatch between what patients expect and what nephrologists know about the effectiveness of dialysis. Patients see dialysis as a treatment that will extend life. They know it’s covered by Medicare, and they expect it. The 1972 Congressional decision to publicly fund dialysis through Medicare has contributed to the perception that pursuing dialysis is nearly always in the patient’s best interest.
Doctors know differently, however. They know that the data show good outcomes with dialysis are less likely as people age. The one-year survival rate for 45-year-olds is 90 percent. For 85-year-olds, it’s about 57 percent. They also know that good outcomes are even less common if elderly patients have comorbidities. Recent research has shown that dialysis may not confer much of a survival advantage in patients who are older than 75 years and have health problems such as diabetes, congestive heart failure, or chronic obstructive pulmonary disease.
Also mounting is evidence that dialysis diminishes the quality of life for certain elderly patients. A study published in the New England Journal of Medicine in 2009 found nursing home residents on dialysis experienced “sharp and sustained” declines in their ability to perform activities of daily living. Such information led the authors of a 2010 article in Hospital Practice to make the case that even though survival among the elderly who do opt for dialysis may be better than among those who opt for medical management, their lives may not be. “Health-related quality of life may be better,” they wrote, “especially if the chronic kidney-disease-associated complications are appropriately addressed through effective palliative care.”
Today, there’s an increasing awareness among nephrologists that they need to approach the conversation about dialysis with elderly, sicker patients somewhat differently than they do with younger, healthier patients. As writer Gina Kolata stated in a New York Times article last March, “Kidney specialists are pushing doctors to be more forthright with elderly people who have other serious medical conditions, to tell the patients that even though they are entitled to dialysis, they may want to decline such treatment and enter a hospice instead.”
Last year, kidney specialists codified that sentiment in a clinical practice guideline. The guideline, issued by the Renal Physicians Association, calls for shared decision-making around initiating dialysis and urges physicians to fully inform patients with end-stage renal disease about their prognosis and treatment options. Physicians, it says, need to inform those chronic kidney disease patients who are elderly, have comorbidities, have marked functional impairment, or have severe chronic malnutrition that dialysis may not help them survive, may not improve their functional status over medical management without dialysis, and may detract from their quality of life.
Conversation Starters
In order to best inform patients, kidney experts recommend that physicians change the terminology they use when discussing options. For example, instead of telling patients they can “forego” dialysis, physicians can instead say they may choose “medical management without dialysis.” The article “Dialysis and the Elderly Patient: Decision, Not Default,” published in Nephrology Times in July 2010 quoted Mark Swidler, M.D., of Mount Sinai Medical Center, as saying doctors need to avoid terms such as “withdraw,” “withhold,” and “forego,” and instead of referring to “conservative therapy” simply refer to “nondialysis therapy.” Swidlers’ argument is that such subtle shifts send the message that patients have a choice between two equally valid therapies, rather than between dialysis and doing nothing.
Nephrologist Bobbi Daniels, M.D., CEO of University of Minnesota Physicians, says her approach is to make sure that patients and their families are aware of their options and have realistic expectations about outcomes. “I like to start off by making sure that patients understand the risks and the benefits and that [they know] they can make the decision to start treatment and that sometime in the future they can make a decision to stop treatment and pursue medical therapy instead of dialysis therapy,” she says. She stresses that there are things that can be done to help patients who choose medication therapy manage their fluids and cope with symptoms such as itching.
Even with the new guideline for shared decision-making, the advice about how to phrase things, and the new data on outcomes, nephrologists say that leading the discussion about whether an older person with other health problems should go on dialysis is challenging. “It’s one of the things that relates to the art of medicine,” Daniels says. “It takes a lot of time to frame the discussion so that patients can make appropriate choices. It takes more time to do that than to just start dialysis.”
Tweeting Your Mood
Cornell University sociologists recently turned to Twitter to study how people’s emotions fluctuate throughout the day.
The researchers studied messages posted by more than 2 million people in 84 countries between February 2008 and January 2010. They analyzed the tweets using a standard computer program that associated words such as “awesome,” “fine,” and “agree” with a positive mood and words like “annoy,” “mad,” and “afraid” with a negative mood. The program also analyzed emoticons.
During the work week, the most positive posts occurred between 6 and 9 a.m. and the most negative ones between 3 and 4 p.m.; the number of positive posts rose sharply in the early evening. On weekends, the morning peak was closer to 9 a.m. and the evening peak closer to 9 p.m.
The researchers also found no evidence that people tweeted more negative remarks during the winter. They did, however, find positive messages increasing around the time of the spring equinox and falling around the autumnal equinox.
The study was published in the September 30, 2011, issue of Science.