Dialysis is a life-saving process that filters impurities from the blood when the kidneys no longer are able to perform that vital function. But a lot of older people whose conditions require kidney dialysis are opting out, choosing a better quality of life over a longer life.
A recent story in the New York Times noted that people older than 75 are the fastest-growing segment of patients on dialysis, and that for them, the value of its benefits versus its side effects is not as clear as they are for younger patients. “A growing number of nephrologists [kidney specialists] and researchers are pushing for more educated and deliberative decision making when seniors contemplate dialysis,” The Times said.
Dialysis is a life saver; the mortality rate for people with chronic kidney disease decreased 42% from 1995 to 2012, according to the United States Renal Data System.
But that’s not true across all age brackets. About 4 in 10 patients older than 75 with end-stage renal disease (advanced kidney failure) die within a year, and not even 1 in 5 live longer than four years. Mostly that’s because they have other dire conditions besides kidney failure that compromise their health, including diabetes, heart disease and lung disease.
“Dialysis only treats the kidney disease,” Dr. Ann O’Hare, a nephrologist, told The Times. “It doesn’t treat the other problems an older person may have. It may even make them more challenging to deal with.”
So although most older adults on dialysis die from a chronic condition other than kidney disease, the process of dialysis has a significant impact on how they spend their remaining months or years. Many of them don’t want to be tied to a time-sucking process while they’re also dealing with other health issues, or would be engaged in other activities if they weren’t married to a dialysis machine.
Dialysis used to be a temporary procedure for people with kidney disease who were awaiting a transplant. But it has become the standard treatment for advanced kidney failure. Although it’s time-consuming and must be undergone frequently, it can happen at home or in a facility.
Fewer than 1 in 10 patients choose peritoneal dialysis, which can be done at home and requires special preparation and training. Hemodialysis occurs at a center.
Usually, a patient undergoes hemodialysis three times a week for three to four hours each time. That doesn’t include the time it takes to get to and from the dialysis center.
Side effects can include cramping, dizziness, pain, nausea and lethargy. A lot of older patients go directly from dialysis to bed.
Dialysis patients are hospitalized a lot, and if they live in a nursing home, their ability to eat, dress, use a toilet and perform other daily activities generally declines noticeably. One study The Times mentioned found that nearly 6 in 10 patients in this situation died within a year of beginning dialysis.
“They’ve bought into a very intensive pattern of medical care that tends to escalate towards the end of their lives,” O’Hare said. She participated in one study that found that 3 in 4 of older dialysis patients were hospitalized in the final month of their life and that half of them were admitted to an intensive care unit.
If you probably have a short lifespan anyway, is dialysis worth it?
A lot of people have decided it isn’t. More than 6 in 10 participants in a Canadian survey said they regretted starting dialysis, which they underwent largely because their doctors and families wanted them to. In an Australian study, 105 patients approaching end-stage kidney disease said it would be worth seven fewer months of life to be able to reduce their number of dialysis visits. They would trade 15 months of longevity for greater freedom to travel.
But those concrete options are only theoretical when you’re in a doctor’s office trying to decide how to treat your progressive kidney failure. “People drift into these decisions because they’re presented as the only recourse,” Dr. V. J. Periyakoil, a geriatrician and palliative care physician, said in The Times story.
Older kidney patients must be informed that there are more conservative approaches than dialysis to treat the disease and improve their quality of life. Medication to control blood pressure, treat anemia and reduce swelling and pain not only can help people feel better for quite a while, but keep them out of the hospital and other medical facilities.
But you can’t make this important decision without being fully informed of all the pros and cons of dialysis. At one dialysis center in North Carolina, 2 in 3 patients at dialysis centers in North Carolina told researchers that their doctors had not mentioned the treatment’s risks or burdens.
The same proportion said they felt they had no choice but to undergo the procedure.
Choosing Wisely is a public campaign to identify procedures that physicians and patients should discuss fully with the idea that they might not be appropriate for their circumstances. The American Society of Nephrology’s advice for Choosing Wisely is not to initiate chronic dialysis without full communication about what it entails among patients, their families and their physicians.
Seventy-four-year-old Gerald J. Hladik was one patient who chose not to have the procedure. His kidneys, The Times reported, had lost 85% of their function when his doctor suggested it was time for dialysis.
But he liked to fish, boat and garden, he liked to spend time at home with his dog, and go to the beach. His son, a nephrologist, understood how drastically his father’s life would change if he spent the time necessary to undergo dialysis. “Dialysis may have prolonged his life, but I suspect only by a couple of months,” Dr. Hladik told The Times.
So Hladik just said no. His doctors managed his other health issues, including heart disease and hypertension, with drugs. He died at home a year and a half after later, with no regrets.