Renal Physicians Association revises guidelines on initiating dialysis

RPA revises guidelines on initiating dialysis
9/20/2010

(This article is posted with permission from the Renal Physicians Association. It was originally published in the September 2010 issue of RPA News, Vol. XXVIII, #4).

 By Alvin Moss, MD

In the late 1990s, nephrologists observed that the incident and prevalent ESRD population had changed substantially, and they increasingly reported that they were being asked to dialyze patients for whom the benefit appeared to be marginal. In this context the Renal Physicians Association leadership assigned the highest priority for clinical practice guideline development to the topic of Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, and in February 2000 this guideline was published. It was based on a systematic medical literature review, and technical and administrative contractor support was provided by the San Antonio Evidence-Based Practice Center and Veterans Administration Cochrane Center. The methodology for the guideline was adapted from the Agency for Health Care Research and Quality guideline process and the American Medical Association’s Attributes for Clinical Practice Guideline Development document.   

RPA’s clinical practice guideline has been widely quoted, and in a 2005 survey of the RPA membership, nephrologists who were aware of the guideline and used its recommendations in making dialysis decisions were statistically significantly more likely to report themselves as being very well prepared for end-of-life decision-making compared to nephrologists who were not aware of the guideline.   

Since 2000, researchers have extensively studied the factors in the guideline’s analytic framework for dialysis decision-making. To develop the second edition of the guideline, RPA conducted a literature search for studies published since 2000 addressing questions derived from the analytic framework. The methodology for the second edition was the same as that established by the San Antonio Evidence-Based Practice Center and VA Cochrane Center. The second edition builds on the solid recommendations in the original guideline and expands the value of the guideline in decision-making because of the following recent research findings: 

* The poor prognosis of some elderly stage 4 and stage 5 chronic kidney disease patients, many of whom are likely to die prior to initiation of dialysis or for whom dialysis may not provide a survival advantage over medical management without dialysis. 
* An online calculator to estimate prognosis in ESRD patients using an integrated model that incorporates the patient’s age, serum albumin, co-morbidities, and clinician assessment of the patient’s likelihood of being dead within a year. “Would I be surprised if this patient died in the next year?” is available at http://touchcalc.com/calculators/sq.  
* The identification of distinctly different treatment goals for ESRD patients based on their overall condition and preferences: 1) patients who choose aggressive therapy with dialysis without limitations on other treatments; 2) patients with a poor prognosis who choose dialysis but with limitations on other treatments such as cardiopulmonary resuscitation, intubation, and mechanical ventilation because they want to balance life prolongation and comfort; and 3) patients who decline dialysis and prefer that the primary goal of care be their comfort. 
* The frequent prevalence of cognitive impairment in dialysis patients and the need to periodically assess dialysis patients for decision-making capacity. 
* The failure of advance directives to impact patient care and the recognition that advance care planning with completion of Physician Orders for Life-Sustaining Treatment (POLST) forms (the name of the form may vary depending upon the state) is the preferred approach for decision-making for patients who lose decision-making capacity. 
* The under recognition and under treatment of pain and other symptoms in dialysis patients. 
* The underutilization of hospice in dialysis patients. 
* An understanding of the communication challenges in discussing prognosis and treatment options with CKD and ESRD patients and their families, and a presentation of strategies to assist nephrologists in this communication. 
* An appreciation that pediatric dialysis decision-making is distinct from that for adults and that sufficient evidence and ethical policy statements exist to make recommendations with regard to pediatric dialysis decision-making. To review the literature and write the second edition of the guideline, RPA coordinated a large voluntary effort in which adult and pediatric nephrologists, intensivists, nurse practitioners, a pediatric psychologist, and a pediatric bioethicist participated in the guideline revision. All participants shared a commitment to improving the process of decision-making about dialysis initiation and withdrawal and received no compensation for their efforts. Their goal was to provide clinicians, patients, and families with 1) the most current evidence about the benefits and burdens of dialysis for patients with diverse conditions; 2) recommendations for quality in decision-making about treatment of patients with acute kidney injury, chronic kidney disease and end-stage renal disease; and 3) practical strategies to help clinicians implement the guideline recommendations.

Numerous organizations representing various constituents have endorsed the second edition of the guideline. The publication will be available for purchase through RPA’s online store at www.renalmd.org on Oct. 1st.      

Dr. Moss is Professor of Medicine and Director, Center for Health Ethics and Law, West Virginia University.  

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