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Practical Considerations in Dialysis Withdrawal: Lewis M. Cohen, MD, discusses practical considerations in dialysis withdrawal.
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Practical Considerations in Dialysis Withdrawal: Lewis M. Cohen, MD, discusses practical considerations in dialysis withdrawal.
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Language: EN.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspectives Section. Today I have the pleasure of talking with Dr. Lewis Cohen about practical considerations in dialysis withdrawal. This topic is discussed in Care at the Close of Life in a chapter co-authored by today's guest. Welcome to the podcast, Dr. Cohen and please introduce yourself to our listeners. >> Thank you, Joan. I'm Lou Cohen. I am a psychiatrist at Baystate Medical Center in Springfield, Massachusetts, and a Professor of Psychiatry at Tufts University School of Medicine.
>> Dr. Cohen, would you please describe for our listeners what are typical indications for patients undergoing dialysis and what comorbid conditions might they have? >> Well, nephrologists have been placing patients on dialysis now since the 1970s when the technology became available. And the type of patients has changed in the ensuing years, but at the present time, it is mainly people who come in with probably one of three situations.
Either they have diabetes and kidney failure as a complication, hypertension where the same thing can happen over the years, or they come from a family where there is a genetic disorder such as polycystic kidney disease. >> What bioethical issues accompany use of dialysis in any discussion of its withdrawal? >> Well, patients, when they begin dialysis, have to have been provided with an informed consent, and they have to really give their OK to go ahead with this life-prolonging treatment.
When they do that, they do it with the understanding that at any point, they can make a decision to retract their permission and to stop the treatment, and this is going to be respected by the healthcare team. What makes dialysis kind of interesting is this is a treatment that people often go on and have for ten plus years, and while in many cases they will remain able to say that they've had enough of the treatment and it will be stopped, in many other cases between the growing age of the patient, the dementing illnesses that come into play, or the delirium that one may see as people get medically compromised, often these decisions are made by healthcare proxies or family members on their behalf.
>> Please tell us about the clinical practice guidelines for withholding and withdrawing dialysis as developed by the American Society of Nephrology and Renal Physicians Association. >> Well, this was a groundbreaking effort that involved the entire dialysis community, and it has since been revised. So there is a newer version that's available online, and it makes life considerably easier for practicing nephrologists and their patients because it spells out a method and number of circumstances related to just who should start dialysis, under what circumstances should we be stopping dialysis, and, again, where that might be questionable.
Most important in the guidelines, though, is the principle of shared decision making, and that informs any and all of these decisions. >> Once a decision has been made to withdraw dialysis, what steps should clinicians take with patients and with the patients' family members? >> Most important are the steps that lead up to that decision and that involves really both acquainting patients and the families with what we know about stopping dialysis and what kind of symptoms they might have and what kind of death they might have so that they go into this decision with their eyes open.
Once the decision is made, the other piece that would be important to sort of set the groundwork for would be referral to hospice. Most of the hospices are eager to help people who have decided to stop dialysis, to help them and to help their families have as symptom-free as time as possible and in turn with the families to help them with the bereavement that comes afterwards. So, again, involvement of hospice is essential and represents good practice.
>> What additional research is needed in the area of dialysis withdrawal? >> Well, our original studies were done with patients who, by and large, were cognitively intact and made the decision to stop dialysis. Now, my own thinking is that that probably represents the minority and that most of the deaths that are occurring are occurring among people who get hospitalized with acute problems in which not only dialysis, but other life support treatments are stopped at the same time.
I think that some prospective research of that patient population is certainly indicated at this point. Lastly, I would also pay attention to the cultural and ethnic aspects of dialysis discontinuation. There's considerable variation among people's either willingness to contemplate it or their decision to make it depending upon, for instance, whether they are white or non-white, and so this is a fertile area that could and should be researched.
>> Is there anything else you would like to tell our listeners about practical considerations in dialysis withdrawal? >> I guess the main thing that I'd like to get across and why I became so interested in this subject was the fact that dialysis discontinuation deaths can not only be good, but they could be extraordinarily good experiences for all concerned, for a patient who is able to say thank you to staff that has taken care of the individual for years, for family to be able to often have a reconciliation with a patient, and for just sort of the general sense that we're doing the right thing at a certain point by acknowledging just how far we can go and just how far we should not go just makes a lot of sense.
That's, I guess, the last words I'd like to say. >> Thank you very much, Dr. Cohen, for this helpful review of practical considerations in dialysis withdrawal, Additional information about this topic is available in Chapter 13 of Care at the Close of Life. This has been Joan Stephenson of JAMA talking with Dr. Lewis Cohen for JAMAevidence.
