Reflections on End-of-Life Dialysis

Correspondence to: Carmen Tzanno-Martins. E-mail: tzanno@gmail.com Chronic kidney disease (CKD) usually progresses more slowly in elderly patients. Therefore, they may stay for longer periods of time on conservative management. Life expectancy and quality of life tend to deteriorate in elderly individuals with pre-dialysis CKD and older patients on dialysis. Furthermore, there is controversy over the benefits of dialysis and when to start or stop it. The first three months of dialysis are critical, with patients experiencing decreases in functional capacity and quality of life.1 Life expectancy decreases, as 69% of the patients aged 75 years or older survive after one year of dialysis and a meager 20% are alive after five years of treatment.2 Individuals aged 90 years or older are expected to survive for eight months.3 The annual census survey of hemodialysis centers organized by the Brazilian Society of Nephrology revealed an increase in the number of individuals aged 65 years or older on dialysis. In the last decade this segment of the patient population increased by 42%, and today approximately 30% of the individuals on dialysis are elderly.4 Elderly patients on dialysis suffer from increased risk of falls5 and present more clinical comorbidities and bouts of severe anemia. Most elderly on hemodialysis are fragile a condition associated with worse clinical outcomes and mortality and partially or completely dependent on family members or caregivers. Old age is also a risk factor for cognitive impairment, which in turn increases mortality by 1.5 to 2 times.6 Reflections on End-of-Life Dialysis

Chronic kidney disease (CKD) usually progresses more slowly in elderly patients. Therefore, they may stay for longer periods of time on conservative management.
Life expectancy and quality of life tend to deteriorate in elderly individuals with pre-dialysis CKD and older patients on dialysis. Furthermore, there is controversy over the benefits of dialysis and when to start or stop it.
The first three months of dialysis are critical, with patients experiencing decreases in functional capacity and quality of life. 1 Life expectancy decreases, as 69% of the patients aged 75 years or older survive after one year of dialysis and a meager 20% are alive after five years of treatment. 2 Individuals aged 90 years or older are expected to survive for eight months. 3 The annual census survey of hemodialysis centers organized by the Brazilian Society of Nephrology revealed an increase in the number of individuals aged 65 years or older on dialysis. In the last decade this segment of the patient population increased by 42%, and today approximately 30% of the individuals on dialysis are elderly. 4 Elderly patients on dialysis suffer from increased risk of falls 5 and present more clinical comorbidities and bouts of severe anemia.
Most elderly on hemodialysis are fragile -a condition associated with worse clinical outcomes and mortality -and partially or completely dependent on family members or caregivers.
Old age is also a risk factor for cognitive impairment, which in turn increases mortality by 1.5 to 2 times. 6
A recent comparative study revealed that dialysis does not improve the survival of individuals aged 80 years or older. 2 Conservative management has been associated with higher levels of patient satisfaction, better quality of life, and mean survival of 13 months. 7 In this issue, the author of "Reflections on Endof-Life Dialysis" covered issues seldom addressed in nephrology services: decision-making; shared decision-making; the tools we have; the vulnerability of physicians; healthcare worker and caregiver burnout. 8 Although healthcare professionals are aware that offering palliative care and early integration of this approach result in improved symptom management and better quality of life without reducing survival, most nephrologists still do not consider this option.
According to the author, who endorsed Kee's study, nephrologists differ on whom to offer dialysis; and what weighs most on this decision is the patient's mental state. 9 The decision to start or discontinue dialysis should be shared and made with the support of assessment instruments. Evaluating disease progression, mortality scores, and patient functional capacity and mental state increases team confidence.
The thought explored by the author in his paper that factors beyond clinical and psychical conditions ought to be considered -including cultural, religious, spiritual, educational, and legal aspects -resonated well with me.
An Internet survey recently organized by the Italian Society of Nephrology found that although nephrologists consider dialysis and chronic kidney disease to be elements inherent to aging, they are unaware of tools that might be used in patient assessment. 10 Geriatricians look at indicators of fragility, functional disability, and risk of unfavorable outcomes. However, nephrologists are not used to resorting to such references and formulas, and seldom use them in their decisions.
The European Best Practice Group recently published a manual with clinical guidelines for elderly patients with CKD stage 3b or more severe, along with scores for clinical management and shared decision support. 11 The BANSAL score 11 is useful for predicting the 5-year risk of death of non-fragile elderly patients with CKD stages III to V.
The REIN 11 (Renal Epidemiology and Information Network) score is useful in the stratification of risk of death of frail elderly patients considered for dialysis.
The Kidney Failure Risk Equation (KFRE) 11 has excellent predictive accuracy of risk of CKD progression.
Considering disease progression, mortality risk, comorbidities, and patient fragility, nephrologists could make shared decisions focusing on renal protection and renal support actions while planning for advanced care and/or pre-dialysis counseling to discuss the choice between modes of dialysis and conservative management. 11 Decisions are often complex and entail a high degree of uncertainty, even when scores and scales are used to aid decision-making and the sharing of responsibility.
A commonly neglected issue that reflects on team performance is burnout, as mentioned by the author. Patients with longstanding chronic diseases and elderly individuals require greater attention from multiprofessional teams and caregivers. Older patients often suffer with loss of independence, absenteeism at work, poor socialization, impoverishment due to reduced income, and increasing expenses with healthcare and family restructuring. Therefore, a trained multiprofessional team and efficient communication and technologies are required to treat these patients.
In 2015, the KDIGO published an executive summary on renal support in CKD on account of the growing population of elderly individuals on dialysis, in an attempt to tackle questions over which might be the best treatments yielding greater benefits.
In addition to the factors considered by the author in his paper, the following might also be deemed as recommendations to improve shared decision-making and the communication between the team, their patients, and caregivers: 1 -Develop a doctor-patient relationship in which decision-making is an integral element.
2 -Inform patients with AKI and CKD stages 4 and 5 of their diagnoses, prognoses and treatment options.
3 -Provide patients with AKI and CKD stages 4 and 5 with a prognosis for their general condition.
4 -Report the care for both renal replacement therapy and renal support. 5 -Avoid starting or discontinuing dialysis when patients and/or their families express a desire for renal support care. 6 -Consider discontinuing or not starting dialysis for patients with AKI and CKD with poor prognoses including end-stage renal disease, medical conditions that hinder dialysis and patients with two or more of the following: • Age of 75 years and older.
• Chronic malnutrition. 7 -Consider offering dialysis for a limited time for patients with uncertain prognoses or unclear benefits from undergoing dialysis.
8 -Establish a conflict resolution plan for shared decisions.
9 -Provide support to manage the symptoms and complications of patients on renal support.
10 -Communicate the decisions to all staff involved.
Life expectancy is on the rise and the number of elderly with chronic diseases tends to increase. Therefore, the reflections proposed by the author are relevant and current. Nephrologists must consider palliative care as a therapeutic option, and find tools to make decisions and share the ensuing challenges with other professionals, caregivers and the patients themselves. Where it was written:

ERRATUM
In this issue, the author of "Reflections on Endof-Life Dialysis" covered issues seldom addressed in nephrology services: decision-making; shared decision-making; the tools we have; the vulnerability of physicians; healthcare worker and aregiver burnout.

Should read:
In this issue, the author of "Reflections on Endof-Life Dialysis" covered issues seldom addressed in nephrology services: decision-making; shared decision-making; the tools we have; the vulnerability of physicians; healthcare worker and aregiver burnout. 8 Where it was written: this decision is the patient's mental state 8 .

Should read:
this decision is the patient's mental state 9 .
Where it was written: tools that might be used in patient assessment. 9 Should read: tools that might be used in patient assessment. 10 Where it was written: scores for clinical management and shared decision support 10 .

Should read:
scores for clinical management and shared decision support 11 . Where it was written: The BANSAL score 10 is useful for predicting the (...)

Should read:
The BANSAL score 11 is useful for predicting the (...) Where it was written: The REIN 10 (Renal Epidemiology and Information Network) (...)

Should read:
The REIN 11

(Renal Epidemiology and Information Network) (...)
Where it was written: the choice between modes of dialysis and conservative management. 10 Should read: the choice between modes of dialysis and conservative management. 11 Where it was written: