When it is time to say enough

When it is time to say enough
December 6, 2010

For some elderly patients, dialysis is not worth it, writes Julie Robotham.

Only one therapy has any real chance of prolonging the lives of Mark Brown's patients, and he usually prefers to talk them out of starting it.

Dialysis may, in a sense, save the lives of people with advanced kidney disease.
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But in Professor Brown's observation, for the elderly it is most often simply not worth the price of relentless hospital visits - usually three a week - and their burden of physical and emotional distress.

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He has come to believe the alternative of keeping people comfortable while their kidney failure brings about their eventual death is ultimately better for many, if not most, people in that predicament.

"When you've got a technology available, the normal response is to use it," said Professor Brown, a renal specialist at St George Hospital, of the dialysis machines now used to filter the blood of more than 10,000 Australians, at a cost approaching $1 billion.

By making explicit the option not to use the technology, and formally acknowledging a natural end-point for active therapy, Professor Brown has put himself and his patients at the centre of a gathering debate: where to draw the treatment line for the growing number of people who avoid cancer, stroke or heart attack, but still face inevitable death from the progressive failure of one of the body's essential organs.

For older people, who, in addition to their struggling kidneys, usually have other medical problems, any benefits from dialysis may simply be too marginal and the residual chance of dying too high to justify the personal cost.

"If you're over 75 in Australia and you go on dialysis there's a 25 per cent death rate in the first year, and [an additional] 25 per cent in the second year," Professor Brown said.

"It's invasive and a very great imposition on people's lives. Over 10 years the quality of life for people on dialysis has improved only slightly."

Professor Brown has pioneered the state's first renal palliative care unit, for those who forgo dialysis, withdraw from it, or are too sick to start. Three-quarters of his new patients have never tried dialysis.

"This has become one of the most rewarding parts, paradoxically, in my 30 years as a doctor," Professor Brown said.

"Our training has always been about keeping people alive. It's less about dying with dignity. When [patients] die it's still tough because you've known them a long time. This is a great service and a positive service but it's never going to be easy."

Symptoms such as severe itching can be treated with medication. When death finally comes, it is relatively gentle. "You'll drift off into a coma and you won't be aware,'' Professor Brown said. ''One of the blessings of the renal death is that it's not a painful death."

The program comes amid a surge in dialysis treatment of the elderly. The annual number of new dialysis patients in their 80s nearly doubled between 2004 and 2008 - the fastest growth of any age group.

Of 792 patients who began dialysis in NSW in 2008, a quarter were aged 75 or older, and 19 were older than 85. By contrast, over the same period in New Zealand fewer than 10 per cent of new dialysis patients were older than 75, and nobody over 85 entered the program.

People who had heart, lung or vascular disease in addition to kidney failure did not extend their lives by entering dialysis, Professor Brown said. But faced with a choice, patients and families might still feel coerced to have treatment.

"Over my years I've developed the approach of trying to guide the patient more forcefully to a decision [not to enter the program]''.

Despite the high cost of dialysis - about $75,000 a year for each patient - Professor Brown said he had never been asked to restrict treatment of the elderly. But "all this technology is going to increase the national expenditure and at some point some leader is going to have to lead a debate about more appropriate selection of patients … It's not a discussion about money.

''It's about the wellbeing of individuals."

Bruce Pussell, a renal specialist and professor of medicine at the University of NSW, said families sometimes resisted advice that dialysis should cease.

''They say, 'You're killing them' and then we say, 'No we're not; the disease is killing them'. We would face that sort of thing 10 or 12 times a year.

"The rise in the dialysis rate has to reach a peak. It can't go on forever."

http://www.smh.com.au/lifestyle/lifematters/when-it-is-time-to-say-enough-20101205-18lex.html