I Hate Dialysis Message Board
Dialysis Discussion => Dialysis: News Articles => Topic started by: okarol on December 06, 2013, 11:56:45 PM
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December 4, 2013, 4:06 pm 9 Comments
Dialysis Raises Hard Questions for Older Patients
By JUDITH GRAHAM
The population of people on dialysis is graying; adults aged 75 and older are the fastest growing group beginning this treatment. But often doctors don’t answer their key question: “How long can I expect to live?”
Researchers at Tufts University and the University of New Mexico underscored the disconnect in a recent review. Ninety-five percent of patients said they and their families want to be given information about life expectancy, the authors noted. But a 2010 survey cited in the study found that 90 percent of patients had never discussed the issue with their nephrologists.
The researchers called for doctors to explain prognosis to patients and undertake shared decision-making, assessing the benefits and burdens of treatment in light of a person’s values. That recommendation has also been adopted by the Renal Physicians Association and the American Society of Nephrology. But the advice is widely ignored in practice.
I interviewed several experts and reviewed almost two dozen scientific reports for some answers about the prognosis for older adults on dialysis.
Q.
What is known about life expectancy among older dialysis patients?
A.
Older people on dialysis have a significantly shortened life expectancy, compared with peers in their age group. This is especially true when they have multiple illnesses: up to one-third of older adults with severe kidney disease have four or more other ailments, such as diabetes, hypertension, heart disease or dementia.
Dr. Jeffrey Berns, who heads the nephrology fellowship program at the Hospital of the University of Pennsylvania, pointed me to some useful data from the United States Renal Data System.
The data show that 70- to 74-year-olds on dialysis can expect to live 3.6 years on average, compared with 12.2 years for all Americans of that age. For 75- to 79-year-olds, the figures dropped to 3.1 years versus 9.2 years. For 80- to 75-year-olds, they were 2.5 years versus 6.7 years. And for those 85 years and older, average life expectancy was two years versus 3.5 years. (The dialysis data is for 2011, and the general population data is from 2009.)
“Some people will do better, and others will do worse,” Dr. Berns said. “It’s hard to predict with any degree of precision, but obviously the more conditions someone has, the less likely it is their life expectancy will be enhanced by starting them on dialysis.”
This is especially true of patients with ischemic heart disease, characterized by reduced blood flow to the heart. “That condition alone is sufficient to negate any potential benefit from dialysis in the elderly,” Dr. Berns said.
Q.
Do other factors affect life expectancy?
A.
Research suggests that older adults who are frail and unable to dress, toilet, bathe, eat on their own or get out of bed in the morning also tend not to live long on dialysis.
“If someone can’t perform multiple activities of daily living, you need to be introspective about whether dialysis adds to their longevity,” said Dr. Leslie Spry, medical director of The Dialysis Center of Lincoln, in Nebraska, and a spokesman for the National Kidney Foundation. “If they’re otherwise relatively healthy and getting around all right, that’s another matter altogether.”
One simple question that draws on the doctor’s clinical judgment — “Would you be surprised if Mr. Smith died within the next six months?” — turns out to be highly predictive of who will survive.
New research from the Mayo Clinic, presented last month at the annual meeting of the American Society of Nephrology, suggests other considerations. The study looked at 379 patients aged 75 and older at the Rochester, Minn., medical center between 2007 and 2011. Slightly more than three-quarters of them began dialysis in the hospital after an acute exacerbation of chronic kidney disease, a severe infection, or an acute kidney injury following surgery.
Those who started dialysis in the intensive care unit (60 percent of the hospital population) did especially poorly. Only 27 percent survived the next six months; 23 percent were alive at one year. Patients who started dialysis in the hospital but outside the I.C.U. had better results initially, but those worsened over time: 12 percent died in the first six months, but only 59 percent were alive after a year.
The Mayo Clinic draws especially ill patients from across the country and the results may not be generalizable. But they suggest that many sick older patients who begin dialysis while in the hospital may not survive for long, according to lead researcher Dr. Bjorg Thorsteindottir, a health care delivery scholar at the Mayo Clinic.
Still, “a healthy elderly patient should absolutely consider dialysis and can do very well,” she said.
Q.
Will I live longer on dialysis than on supportive therapy?
A.
Most studies suggest that older adults on dialysis will live longer than those who decide against this treatment and choose instead to treat symptoms such as pain or nausea — so-called supportive therapy. According to a review of studies of patients on supportive therapy, life expectancy was at least six months, with a range of up to 24 months. On average, that is shorter than the life expectancy for older adults on dialysis.
But in general, the evidence supporting a survival advantage in very old patients on dialysis is weak, according to Dr. Thorsteindottir. And there’s growing concern among experts that too many elderly patients with severe kidney disease may be starting dialysis without the potential for significant benefit.
“Concerns about overtreatment are focused on older adults, especially those who are frail or have other severe or life-limiting conditions,” according to the authors of an editorial in The Journal of the American Medical Association last year.
The bottom line: older patients and their families deserve to understand what they can expect when a physician recommends dialysis. This is a demanding treatment and one whose potential benefits and burdens deserve careful consideration.
This post has been revised to reflect the following correction:
Correction: December 6, 2013
An earlier version of this post misstated the results of a study of patients aged 75 and older in Rochester, Minn. The study found that of the patients who started dialysis in the intensive care unit, 23 percent were alive at one year. It is not the case that 23 percent died within a year.
http://newoldage.blogs.nytimes.com/2013/12/04/dialysis-raises-hard-questions-for-older-patients/?_r=0
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OMG! I haven't got long to go!
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I don't have long to go either and now it is making me wonder if I should even start to do Dialysis. Mmmm, creepy!!!
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Remember, it is the other diseases (comorbidities) that are really key here. Dialysis alone doesnt really shorten life expectancy .
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Yes, of course. I also have CHF and some serious arthritis. Still, it is something to think about. I never thought I would make it to 75, but I am pretty tough and active too. Oh well, we were all born knowing we would die.
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Yes,well I have cogestive cardiac failure (4 infarcts), Type 2 diabetes, hypertension, and sundry other health problems including diabetic neuropathy. I am 71 and have been on HD for over 4 years.
Despite all this, I am planning to celebrate Christmas!
But,seriously, if I didn't have my little Camilla to care and worry about, I'd glady pop off tomorrow. I am not happy with the restrictions that dialysis imposes.
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Oh, of course we will celebrate Christmas. I don't mind dying so much, I just don't want it to hurt. And if it were not for my DH, my kids, my love of cooking and baking, my dear little cat Simon, all of my friends at our clubhouse and all of our activities, oh shucks, I am just not going to go.
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I'm asking Santa to bring me a shovel for Christmas. And I'm going to dig a 6 feet hole in the backyard!
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Oh sure, then you will probably start digging a hole and have the big H and fall into it.
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Responding to the opening post:
At age 73 I was in and out of consciousness and hallucinating when they rolled me into the hospital.. I woke up four days later as a dialysis machine next to the bed cranked away. Renal failure, the doctor said. She also said I had about two weeks to live had I not been attached to a dialysis machine. Worse, the renal failure was caused by cancer. As it was explained to me, the three tumors blocked the kidney function. I can't explain it better than that.
For the next eight months I lived for the dialysis machine in an RAI center. Dialysis dominated my life. At the same time I was on chemotherapy which continues today. By the time I recovered 25% of a kidney function, I was 74. Today I have a 40% kidney recovery.
I recall asking my doctor the very same question the article addresses, "How long will I live?"
My Nephrologist said a few years, my Oncologist said as long as I want to live and that I was in otherwise good health. I try to ignore that ordeal, I put it behind me. There are other challenges in life - not the least is my battle to get off painkillers that began the day I was wheeled into that hospital. Against medical advise, I cut six pills a day down to two, a kind of cold turkey. I have never suffered such misery in my life. Trial by fire, I suspect.
So, what is the point? None of these things are going to end my life and I am not planning to go anytime soon. While I am a veteran of this cancer business (began in 1993), I would never minimize the misery of dialysis. Old age, if we can characterize 75 as old age, is a lesson in independence, survival and adjustment. Regardless of experiences in living, most seniors are making decisions with little support. Doing the best they can. Challenges mount until the day.
The young among us have dialysis options that may not be available to the older generations; home dialysis, no caregiver, no help - meaning, the only course of action is the dialysis center. Some of these places look like next door to the mortuary. They line you up against the wall, hook you up, then abandon you for the best hours of the day. Senior patients deserve something better - and don't we all. There is no positive reinforcement in a dialysis center, you are left to your own wits to continue. For a senior citizen, that requires one hell of an effort.
Live life! Live until you die but don't quit, no matter the odds. Fu .. . . . er, screw the odds.