"Gerald J. Hladik was  when the day long anticipated by his doctors arrived His kidneys damaged years earlier by a viral infection had lost  percent of their function. Time to begin dialysis. But from the beginning Mr. Hladik resisted. An IBM retiree he loved fishing boating and gardening  and hated hospitals. He said I dont want to spend my time doing this  recalled his son Dr. Gerald A. Hladik http He wanted to be at home with his dog. He wanted to be able to go to the beach. A nephrologist at the University of North Carolina School of Medicine Dr. Hladik understood better than most how kidney dialysis could consume a patients days. His fathers eventful medical history included a serious stroke and coronary bypass surgery. Dialysis may have prolonged his life but I suspect only by a couple of months Dr. Hladik said. So after considerable discussion Mr. Hladik decided to skip the three weekly trips to a renal center along with the resulting fatigue and dietary and travel restrictions. His doctors managed his heart disease and hypertension with drugs. He died at home http_idfh_id in November a year and a half after saying no to dialysis. People over age  are the fastestgrowing segment of patients on dialysis and the treatments benefits and drawbacks add up differently for them than for younger patients. A growing number of nephrologists and researchers are pushing for more educated and deliberative decision making when seniors contemplate dialysis. It is a choice they say not an imperative. Patients are not adequately informed about the burdens. All theyre told is You have to go on dialysis or youll die  said Dr. Alvin H. Moss http a nephrologist at West Virginia University School of Medicine and chairman of the Coalition for Supportive Care of Kidney Patients http Nobody tells them You could have up to two years without the treatment without the discomfort with greater independence.  Dialysis involves filtering impurities from the blood when a patients faltering kidneys can no longer do so. Originally a temporary stopgap for those awaiting transplants it has become the standard treatment for advanced kidney failure. Fewer than  percent of patients opt for peritoneal dialysis http which can be done at home. Most undergo hemodialysis http at a center where machines clean the blood and correct chemical imbalances. Unquestionably dialysis has helped save lives. The mortality rate for patients with chronic kidney disease decreased  percent from  to  according to the most recent report from the United States Renal Data System http The picture for older patients in particular is less rosy. About  percent of patients over age  with endstage renal disease or advanced kidney failure die within a year httpjasn.asnjournals.orgcontent.abstract and only  percent survive beyond four years the renal data system has reported. A primary reason is that older patients like Mr. Hladik generally suffer from other chronic conditions including diabetes heart disease and lung disease. Editors Picks  Dialysis only treats the kidney disease said Dr. Ann OHare httpsdepts.washington.edunephrondirectorybiosohare.html a nephrologist at the University of Washington School of Medicine. It doesnt treat the other problems an older person may have. It may even make them more challenging to deal with. Most older adults on dialysis die not from kidney disease but from one of their other illnesses. But dialysis profoundly affects the way those patients spend their remaining months or years. Typical hemodialysis sessions take place three times a week and each lasts three to four hours not including travel  a regimen Dr. OHare compares to holding down a parttime job. Afterward patients may have cramping. They can feel dizzy washed out Dr. Moss said. Many report pain or nausea. A typical older dialysis patient will say I just go home afterwards and go to bed  Dr. Moss said. After the good day that usually follows the cycle repeats. Dialysis patients are frequently hospitalized. If they live in nursing homes their independence  as measured by the ability to eat dress use a toilet and perform other daily activities  declines sharply. In this ailing population one study found  percent died within a year of beginning dialysis http Theyve bought into a very intensive pattern of medical care that tends to escalate towards the end of their lives Dr. OHare said. She was a coauthor of a study that found that  percent of older dialysis patients were hospitalized httparchinte.jamanetwork.comarticle.aspxarticleid in the final month of life half were admitted to an intensive care unit. Do older people with advancing kidney disease really intend to sign up for all this If they hope to reach a particular milestone  a greatgrandchilds birth say  or value survival above all perhaps so. But many express ambivalence. Sign up for Science Times Well bring you stories that capture the wonders of the human body nature and the cosmos. Advertisement In a Canadian survey  percent of patients said they regretted starting dialysis httpcjasn.asnjournals.orgcontent.full a decision they attributed to physicians and families wishes more than their own. In an Australian study  patients approaching endstage kidney disease said they would willingly forgo seven months of life expectancy http to reduce their number of dialysis visits. They would swap  months for greater freedom to travel. In realworld hospitals and nephrologists offices of course patients arent offered such tradeoffs. People drift into these decisions because theyre presented as the only recourse said Dr. V. J. Periyakoil httpsmed.stanford.eduprofilesvjperiyakoil a geriatrician and palliative care physician at Stanford University School of Medicine. More conservative approaches to kidney disease do exist and can improve older patients quality of life. Medication to control blood pressure treat anemia and reduce swelling and pain these are treatments that will keep people comfortable for long periods Dr. Moss said. People choosing medical management could live  to  months  months. And spend less of that time in medical facilities. To weigh the pros and cons however kidney disease patients need better information. Among  patients at dialysis centers in North Carolina for instance twothirds told researchers their doctors had not mentioned the treatments risks or burdens httpndt.oxfordjournals.orgcontent.full. The same proportion said they felt they had no choice. But they do. And they can discontinue dialysis. Withdrawal from that treatment accounted for about a quarter of deaths of dialysis patients in  according to a  presentation to the American Association of Hospice and Palliative Medicine httpaahpm.org. In its contribution to the Choosing Wisely http campaign which identifies procedures that physicians and patients should question the American Society of Nephrology cautioned http Dont initiate chronic dialysis without ensuring a shared decisionmaking process between patients their families and their physicians. Otherwise older patients may not fully grasp what lies ahead. When they decide to discontinue dialysis Dr. Moss said patients say to me Doc its not that I want to die but I dont want to keep living like this."