Renouncement of renal replacement therapy: withdrawal and refusal

Renouncement of renal replacement therapy (RRT) is a medical dilemma. This review covers the concept, the magnitude, the prognosis, and discusses strategies and management approaches about this subject in patients with CKD and AKI. Evidence suggests that refusal is more frequent and carries a more guarded prognosis than withdrawal of RRT. When RRT is not expected to be beneficial in terms of survival or quality of life, conservative treatment and palliative care are alternatives. We review the historical evolution of guidelines about renouncement of RRT and palliative care, and highlight the absence of specific recommendations in Brazil. However renouncement of RRT may be ethically and legally accepted in Brazil, as the right to a dignified death. Longer life expectancy, economic pressures, and greater awareness will require a more detailed discussion about indications and sustainable use of RRT, and possibly the elaboration of national guidelines.

Keywords:
dialysis; renal dialysis; palliative care; bioethics; acute kidney injury; renal replacement therapy; geriatrics; medical futility; withholding treatment; kidney failure, chronic

Authorship

José Andrade Moura NetoCorrespondence to: José Andrade Moura Neto. Unidade Docente Assistencial de Nefrologia, Hospital Universitário Pedro Ernesto. Rua Boulevard Vinte e Oito de Setembro, nº 77/3º Andar, Rio de Janeiro, RJ, Brazil. CEP: 20551-030. E-mail: jamouraneto@hotmail.com

Universidade do Estado do Rio de Janeiro.Universidade do Estado do Rio de JaneiroBrazilBrazilUniversidade do Estado do Rio de Janeiro.

Escola Brasileira de Administração Pública e de Empresas - FGV.FGVBrazilBrazilEscola Brasileira de Administração Pública e de Empresas - FGV.

Grupo CSB.Grupo CSBBrazilBrazilGrupo CSB.

Ana Flávia de Souza Moura

Universidade do Estado do Rio de Janeiro.Universidade do Estado do Rio de JaneiroBrazilBrazilUniversidade do Estado do Rio de Janeiro.

Grupo CSB.Grupo CSBBrazilBrazilGrupo CSB.

José Hermógenes Rocco Suassuna

Universidade do Estado do Rio de Janeiro.Universidade do Estado do Rio de JaneiroBrazilBrazilUniversidade do Estado do Rio de Janeiro.

Correspondence to: José Andrade Moura Neto. Unidade Docente Assistencial de Nefrologia, Hospital Universitário Pedro Ernesto. Rua Boulevard Vinte e Oito de Setembro, nº 77/3º Andar, Rio de Janeiro, RJ, Brazil. CEP: 20551-030. E-mail: jamouraneto@hotmail.com

SCIMAGO INSTITUTIONS RANKINGS

Universidade do Estado do Rio de Janeiro.Universidade do Estado do Rio de JaneiroBrazilBrazilUniversidade do Estado do Rio de Janeiro.

Escola Brasileira de Administração Pública e de Empresas - FGV.FGVBrazilBrazilEscola Brasileira de Administração Pública e de Empresas - FGV.

Grupo CSB.Grupo CSBBrazilBrazilGrupo CSB.

Tables

Tables (1)

Thumbnail

Table 1
2010 Guidelines of the renal physicians association and the american society of nephrology.⁴⁷47 Hirsch DJ, West ML, Cohen AD, Jindal KK. Experience with not offering dialysis to patients with a poor prognosis. Am J Kidney Dis 1994;23:463-6. DOI: http://dx.doi.org/10.1016/S0272-6386(12)81012-2
http://dx.doi.org/10.1016/S0272-6386(12)...

Table 1 2010 Guidelines of the renal physicians association and the american society of nephrology.⁴⁷47 Hirsch DJ, West ML, Cohen AD, Jindal KK. Experience with not offering dialysis to patients with a poor prognosis. Am J Kidney Dis 1994;23:463-6. DOI: http://dx.doi.org/10.1016/S0272-6386(12)81012-2
http://dx.doi.org/10.1016/S0272-6386(12)...

Establishing a shared decision-making process

Recommendation 1

Develop a patient-physician relationship that promotes shared decision-making.

Informing patients

Recommendation 2

Fully explain the diagnosis, prognosis, and all treatment options to patients with AKI, CKD stages 4 and 5 or established kidney failure

Recommendation 3

Provide patients with AKI, CKD stage 5 or established renal failure specific prognostic estimates concerning their global condition.

Facilitating advanced healthcare directives

Recommendation 4

Establish an advanced care plan.

Making the decision to withhold or withdraw dialysis

Recommendation 5^* * Clinical treatment, including palliative care, is an integral component of the decision to discontinue dialysis for patients with AKI, CKD or established renal failure. The healthcare team in charge must strive to provide patients with comfort and quality of life, either directly or through referral to palliative or hospice care for terminally ill patients (see Recommendation 9).

If appropriate, withhold dialysis for patients with AKI, CKD stage 5 or established renal failure meeting the following criteria:

• Patient with decision-making capacity who, being fully informed and making voluntary choices, refuses dialysis or requests that dialysis be discontinued.

• Patient who no longer possesses decision-making capacity who has previously indicated refusal of dialysis in an oral or written advance directive.

• Patient who no longer possesses decision-making capacity and whose properly appointed legal agent refuses dialysis or requests that it be discontinued.

• Patient with irreversible, profound neurologic impairment such that he/she lacks signs of thought, sensation, purposeful behavior, and awareness of self and environment.

Recommendation 6

Consider not initiating or withdrawing dialysis for patients with AKI, CKD stage 5 or established renal failure who have very poor prognosis or whose medical condition precludes the safe administration of dialysis. This category includes patients in the following situations:

• Medical condition that precludes the technical process of dialysis for lack of cooperation (e.g.: patients with advanced dementia who pull out the dialysis needles) or clinical instability (e.g.: severe hypotension).

• Non-renal terminal disease (except for individuals who may benefit from dialysis and decide to be treated)

• CKD stage 5, age > 75 years, presenting two or more significant criteria for poor prognosis (see Recommendations 2 and 3): 1) when the answer to the surprise question is no (see text); 2) high comorbidity score 3) significant functional disorder (e.g.: Karnofsky performance scale index < 40) and 4) severe chronic malnutrition (e.g.: serum albumin < 2.5g/dl).

Resolving conflicts over decisions concerning dialysis

Recommendation 7

Consider offering dialysis for a limited trial period when patients with uncertain prognoses need dialysis but consensus has not been reached as to when to start treatment.

Recommendation 8

Establish a systematic approach to resolve conflicts arising from decisions concerning dialysis when disagreement exists regarding when to start or whether to continue dialysis.

Providing effective palliative care

Recommendation 9

In order to improve patient-centered outcomes, offer palliative care and interventions to all patients with AKI, CKD or established renal failure suffering with the burden of renal disease.

Recommendation 10

Use a systematic approach to inform patients of their diagnoses, prognoses, treatment options, and care goals.

^*
Clinical treatment, including palliative care, is an integral component of the decision to discontinue dialysis for patients with AKI, CKD or established renal failure. The healthcare team in charge must strive to provide patients with comfort and quality of life, either directly or through referral to palliative or hospice care for terminally ill patients (see Recommendation 9).

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E-mail: bjnephrology@gmail.com

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Renouncement of renal replacement therapy: withdrawal and refusal

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[1] Correspondence to: José Andrade Moura Neto. Unidade Docente Assistencial de Nefrologia, Hospital Universitário Pedro Ernesto. Rua Boulevard Vinte e Oito de Setembro, nº 77/3º Andar, Rio de Janeiro, RJ, Brazil. CEP: 20551-030. E-mail: jamouraneto@hotmail.com