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2017 ; 18
(1
): 61
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The strange case of Mr H Starting dialysis at 90 years of age: clinical choices
impact on ethical decisions
#MMPMID29121886
Piccoli GB
; Sofronie AC
; Coindre JP
BMC Med Ethics
2017[Nov]; 18
(1
): 61
PMID29121886
show ga
BACKGROUND: Starting dialysis at an advanced age is a clinical challenge and an
ethical dilemma. The advantages of starting dialysis at "extreme" ages are
questionable as high dialysis-related morbidity induces a reflection on the cost-
benefit ratio of this demanding and expensive treatment in a person that has a
short life expectancy. Where clinical advantages are doubtful, ethical analysis
can help us reach decisions and find adapted solutions. CASE PRESENTATION: Mr. H
is a ninety-year-old patient with end-stage kidney disease that is no longer
manageable with conservative care, in spite of optimal nutritional management,
good blood pressure control and strict clinical and metabolic evaluations;
dialysis is the next step, but its morbidity is challenging. The case is analysed
according to principlism (beneficence, non-maleficence, justice and respect for
autonomy). In the setting of care, dialysis is available without restriction;
therefore the principle of justice only partially applied, in the absence of
restraints on health-care expenditure. The final decision on whether or not to
start dialysis rested with Mr. H (respect for autonomy). However, his choice
depended on the balance between beneficence and non-maleficence. The advantages
of dialysis in restoring metabolic equilibrium were clear, and the expected
negative effects of dialysis were therefore decisive. Mr. H has a
contraindication to peritoneal dialysis (severe arthritis impairing
self-performance) and felt performing it with nursing help would be intrusive.
Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily
life of haemodialysis patients are closely linked to the classic thrice-weekly,
four-hour schedule. A personalized incremental dialysis approach, starting with
one session per week, adapting the timing to the patient's daily life, can limit
side effects and "dialysis shock". CONCLUSIONS: An individualized approach to
complex decisions such as dialysis start can alter the delicate
benefit/side-effect balance, ultimately affecting the patient's choice, and
points to a narrative, tailor-made approach as an alternative to therapeutic
nihilism, in very old and fragile patients.
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