Renaud Clement, Pascal Chevalet, Olivier Rodat, Vincent Ould-Aoudia, Michel Berger, Withholding or withdrawing dialysis in the elderly: the perspective of a western region of France, Nephrology Dialysis Transplantation, Volume 20, Issue 11, November 2005, Pages 2446–2452, https://doi.org/10.1093/ndt/gfi012. Do families and physicians decide as patients do? Fifth, we excluded the dementia cases diagnosed within the first 3 months following dialysis to avoid potential mis-ascertainment of dementia, because various medical conditions could lead to neurological complications soon after dialysis initiation. 2007;50(2):270–8. Timely identification of dementia in ESRD patients is important, because dementia is associated with many adverse outcomes, including disability, hospitalization, impaired quality of life, dialysis withdrawal, and mortality [1, 11,12,13,14,15]. Moreover, some think that the decision to discontinue haemodialysis should be made only by the doctor following substantial discussion with the caregiving team and the family, since it is a medical decision. In 1981 in Canada, only 25% of patients receiving haemodialysis were over 65 years old. In the early 1960s, the Seattle Artificial Kidney Center systematically refused to provide haemodialysis to individuals over the age of 45 [9]. Nearly all kinds of medical services, including outpatient and inpatient services, medications, and intervention procedures, are reimbursed by the NHI. Valderrabeno F, Jones EHP, Mallick NP. JAMA. YTK, JLW, and YTC contributed to the data acquisition. Individually, the practitioners were requested not to provide information about their qualifications or status prior to the interview, or about the nature and duration of their professional experience with dialysis. After stopping dialysis, most patients die in less than two weeks; 96% die within a month. PubMed  The reasons given by the interviewed nephrologists for refusing initiation of haemodialysis in elderly patients were confirmed by the responses they gave to individual patient selection criteria in the questionnaire. Fourth, the non-ESRD group might have enrolled CKD-ND patients, who were also at risk for dementia, and thus might lead to underestimation of dementia risk associated with ESRD. The overall and age- and sex-specific and cumulative incidence rates for dementia were higher in the ESRD group than in the non-ESRD group (Additional file 1: Table S3 and Additional file 1: Figure S1). Undergoing dialysis can cause severe agitation for patients with dementia. In France the medical decision to forego dialysis is deemed legitimate only if there is both a major loss of autonomy and isolation from the family or from society [8]. Kurella M, Mapes DL, Port FK, Chertow GM. Similar phenomenon could also be observed in subdistribution hazards for various subtypes of dementia and their corresponding all-cause mortalities (Table 3). However, younger, less experienced nephrologists would be more readily prepared to accept a patient's refusal to undergo extra-renal treatment or a patient's desire for its discontinuation. Neuromuscular disease in the dialysis patient: an update for the nephrologist. If a patient attended the session, then consent was implicit. (Specialist Nurse, Unit 8) ESRD could also increase the cause-specific hazards of various subtypes of dementia, including Alzheimer’s disease (csHR : 2.71, 95% CI [2.12–3.45]), vascular dementia (csHR : 2.22, 95% CI [1.93–2.54]), or unspecified dementia (csHR : 2.01 95% CI [1.90–2.13]) (Table 3). As the mortality rates of ESRD patients are higher in the USA and Europe than in Taiwan, this effect might be more pronounced in these areas [38, 39]. First, the data used in this study was from two representative national cohorts of the ESRD and non-ESRD populations, which could minimize potential selection bias and make the study results more generalizable. … 2005;46(1):200–4. There may come a time when you feel you want to discontinue dialysis treatment. Doctors in the US, on the other hand, feel that the desire to discontinue haemodialysis does not constitute a suicidal act when expressed by the patient. Patients are free to choose whether or not to come. Competing risk analyses including cause-specific and subdistribution proportional hazards models were then constructed with adjustments for potential confounders. Adv Chronic Kidney Dis. However, before making this decision, it is important that you discuss it carefully with your loved ones and treatment team. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Second, the identification of dementia or comorbidities was solely dependent on ICD-9 codes, and coding errors would thus potentially lead to information bias. In the latter circumstance, many practitioners were willing to begin haemodialysis for a very short period. Death after withdrawal from dialysis: the most common cause of death in a French dialysis population. Variation in the attitudes of dialysis unit medical directors toward decision to withhold and withdraw dialysis. However, the refusal of the patient did present them with complications. Figure S1. Continuous variables were compared by Student’s t test, and comparisons of difference between categorical variables were analyzed by the chi-square test or Fisher exact test. Geneva: World Health Organization. 2002;91(2):344–7. Google ScholarÂ. Jassal SV, Devins GM, Chan CT, Bozanovic R, Rourke S. Improvements in cognition in patients converting from thrice weekly hemodialysis to nocturnal hemodialysis: a longitudinal pilot study. Table 4 shows all of the factors that could be taken into account in reaching the decision not to initiate haemodialysis in elderly patients. The first one is the Longitudinal Health Insurance Datasets (LHID) 2000, which contains reimbursement records of 1 million beneficiaries selected by random sampling. Non-dialysis-dependent chronic kidney disease, International Classification of Disease, Ninth Edition. 2012;308(18):1906–14. Two practitioners expressed regret over having discontinued haemodialysis. J Am Soc Nephrol. Ministry of Health and Welfare, R.O.C.(Taiwan). Cuyvers E, Sleegers K. Genetic variations underlying Alzheimer’s disease: evidence from genome-wide association studies and beyond. Murray AM, Tupper DE, Knopman DS, Gilbertson DT, Pederson SL, Li S, Smith GE, Hochhalter AK, Collins AJ, Kane RL. Cheng CL, Lee CH, Chen PS, Li YH, Lin SJ, Yang YH. Until 1980 in Great Britain very few patients over the age of 60 commenced haemodialysis treatment [10]. Only when the baseline hazard rate of the competing event is zero will the value of the csHR be equal to that of the sdHR [32]. Semin Dial. 2006;1(5):1000–5. Patients with advanced dementia who do not understand the dialysis treatment and cannot cooperate with it are patients for whom stopping dialysis should be considered. This again suggests that the risk of dementia is inversely related to increased mortality while aging. Association between nucleoside analogues and risk of hepatitis B virus-related hepatocellular carcinoma recurrence following liver resection. The nephrologists interviewed stated that, from among the factors involved, severe dementia (15 out of 17 nephrologists), severe and irreversible neurological sequelae of stroke (14 out of 17) and, paradoxically, refusal by the patient (11 out of 17) would be foremost among the factors governing their decision to discontinue haemodialysis (Table 7). Cognitive impairment in the aging dialysis and chronic kidney disease populations: an occult burden. Pharmacoepidemiol Drug Saf. Despite the common concerns and frustrations with this behaviour, there is a scarcity of information available addressing this issue. Demographic and baseline characteristics of the end-stage renal disease (ESRD) and non-ESRD population in the sensitivity analyses, for which dementia is diagnosed by neurologists and psychiatrists. At the end of 1994, ∼650 000 ESRD patients worldwide were receiving a form of renal dialysis: 85% were receiving haemodialysis, 15% were receiving peritoneal dialysis. It is, therefore, a decision with the most serious consequences. Furthermore, the opposite direction of csHRs (> 1) and sdHRs (< 1) for the association between ESRD and risk of dementia noted in our study could happen if both the effect of cause-specific hazard ratios associated with all-cause mortality is strong enough and the baseline cause-specific hazard rate for all-cause mortality is of great magnitude [32], as shown in Table 3 and Additional file 1: Table S4. In addition, the role of ESRD for cumulative risk of dementia should be emphasized only when the mortality rates of ESRD patients can be effectively reduced. Since the brain and kidney have similar microvascular structures and hemodynamic fluctuations, both organs share some common risk factors for vascular damage, including inflammation, atherogenesis, and oxidative stress [5,6,7]. Am J Kidney Dis. For each aspect, might a practitioner have personally influenced a patient's decision to forego treatment? Murray AM. The severity of multicollinearity between independent variables was evaluated by the variance inflation factors. In certain countries, although age is no longer an exclusion criterion, there is a tendency to rely upon other factors to discontinue or refuse haemodialysis. Yes, many Chronic Kidney Disease patients who conduct Dialysis suffer from severe panic and anxiety. Lancet Neurol. 2011;57(4):612–20. Excerpts from the United States renal data system 2006 annual data report. Lau B, Cole SR, Gange SJ. In the opinion of those nephrologists interviewed, the criteria for refusing haemodialysis were cognitive disorders with severe dementia and severe irreversible neurological diseases. Stratified analysis of risk for dementia between the end-stage renal disease (ESRD) and non-ESRD population by using multivariable cause-specific* (A) and subdistribution* (B) hazard models in the sensitivity analyses, for which dementia is diagnosed by neurologists and psychiatrists (DOCX 223 kb). Manage cookies/Do not sell my data we use in the preference centre. Fukunishi I, Kitaoka T, Shirai T, Kino K, Kanematsu E, Sato Y. BMC Med. You are encouraged to discuss your reas… Kjellstrand MC. 2009;19(3):500–8. Though it’s a natural part of the progression of the disease, there are several things you can do to try and halt its progress and help your loved one enjoy mealtimes and stay healthy for as long as possible. 2009;361(16):1539–47. The second database contains a specific cohort of all ESRD patients registered in the Catastrophic Illness Datasets and receiving more than three consecutive months of dialysis therapy during January 1, 1998, to December 31, 2010. The higher disease severity of specific illnesses should combine with more risk factors for developing dementia. Factors assessed in US long-term dialysis patients with Medicare/Medicaid claims for dementia versus those without dementia a Patients with dementia (12.4%) were significantly more likely to discontinue dialysis before death than those without dementia (7.5%; P < 0.001 by χ 2). First, while we tried our best to control for as many confounders as possible in the regression models, there are still residual confounding due to incomplete adjustment for all risk factors for dementia, such as low education level, medications, and disease severity. 2016;133(6):601–9. The benefit of beginning haemodialysis and maintaining life is intrinsically linked to the patient's social condition. 2011;58(2):228–34. Cohen LM, Dobscha SK, Hails KC et al. They felt that they had consciously made decisions that were cruel to their patients, because they had put them through the treatment. Second, we applied different approaches, including subgroup and sensitivity analyses, to validate the study results, and these all lead to the same conclusion and suggest the robustness of our findings. Individuals were defined as having dementia if the diagnosis was recorded once or more at inpatient care or twice or more at ambulatory care with a minimum interval of > 30 days within 1 year. The study period of both ESRD and non-ESRD populations was from January 1, 1998, to December 31, 2010. HealthDay Reporter. In addition, the competing risk regression analyses with both cause-specific and subdistribution hazard models (i.e., Fine and Gray model) were conducted. Nevertheless, ESRD was associated with decreased absolute risk of dementia over time because its sdHRs were less than 1 (Table 3). Cognitive impairment in hemodialysis patients is common. None of the funding sources had any role in the study design, analysis and interpretation of the data, the preparation, review, or approval of the manuscript. Finally, the practitioners were asked if they had obtained the patient's consent before each dialysis session. Dialysis treatment withdrawal-Legal aspects (UK). Numerous risk factors of dementia, including diabetes, hypertension, hyperlipidemia, and stroke, were prevalent in the ESRD population (Table 1), and these comorbidities were also associated with increased risk for the occurrence of dementia over time (all sdHRs > 1 with statistical significance, data not shown in the table). In the US, 20% of renal dialysis candidates chose to forego haemodialysis. 2008;23(12):3977–82. 2004;66(6):2361–7. Correlates and outcomes of dementia among dialysis patients: the Dialysis Outcomes and Practice Patterns Study. The effect of ESRD on the etiology and cumulative risk of dementia is still consistent after adjusting for multiple confounders among most of the age, sex, and selected comorbidity stratifications (Fig. 3 and Additional file 1: Figure S2). Irreversible neurological sequelae of stroke would influence 64% of nephrologists to take the same position. This study was conducted after approval by the Institutional Review Board of the National Cheng Kung University Hospital (A-ER-101-089). Patient refusal is taken into account when a physician refuses initiating haemodialysis, but it is tempered by a second opinion, or by the desire of the doctor to oppose this ‘reticence’. In a retrospective analysis in the UK of outcome in very elderly patients, the cause of 38% of deaths was withdrawal of dialysis [16]. As clinicians we also may be uncomfortable taking away medications, as we are trained to always “do” something. None of the nephrologists interviewed requested the patient's consent before each haemodialysis session. 2005;45(6):1058–66. A study was performed in Japan to elicit the preferences of patients on haemodialysis with regard to the continuation of the dialysis if they were severely demented or had terminal cancer [21]. http://www.who.int/mental_health/neurology/dementia/dementia_thematicbrief_epidemiology.pdf, https://www.mohw.gov.tw/cp-137-522-2.html, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/, https://doi.org/10.1186/s13195-019-0486-z. It acts as a representative cohort for more than 23.75 million people with insurance during 1996–2000. Kalirao P, Pederson S, Foley RN, Kolste A, Tupper D, Zaun D, Buot V, Murray AM. Patients who choose to stop or not start dialysis are not required to eat or take in fluids. The interviewees felt that severe dementia (15 out of 17 nephrologists), irreversible neurological sequelae of a CVA (11 out of 17) and, paradoxically, patient refusal (10 out of 17) were factors to be taken into account in the decision to discontinue haemodialysis. The doctor may also advise stopping the treatment if the person becomes unable to take the medicines in the way prescribed, even with support from someone else. An empirical study of withdrawal of life supporting treatment. Yes, dialysis patients are allowed to make decisions about stopping dialysis treatment. Although cognitive disorders, severe dementia and severe and irreversible neurological conditions in the candidates under consideration justified refusal to start haemodialysis, in no case did any of these factors totally determine the final decision. Might a practitioner have personally influenced a patient's decision to forego treatment? volume 11, Article number: 31 (2019) © 2021 BioMed Central Ltd unless otherwise stated. All of the evidence demonstrates that ESRD patients are more likely to experience higher risk for cognitive impairments and thus supports our study results that ESRD and/or hemodialysis procedure is one of the etiological factors for dementia incidence. International Classification of Disease, Ninth Edition (ICD-9-CM) codes used to identify the associated comorbidities in the study. A questionnaire was written on the basis of bibliographical information. J Am Soc Nephrol. Available at: http://www.who.int/mental_health/neurology/dementia/dementia_thematicbrief_epidemiology.pdf. Increases in financing provided specifically for dialysis, and technical progress made in the provision of renal replacement treatment are two factors that have enabled the oldest ESRD patients to receive such treatment. Practitioners were then each asked to provide a personal, subjective estimate of the number of occasions on which they had received a request to not initiate or to discontinue haemodialysis during their careers. Nevertheless, the difference in IR ratios between the ESRD and non-ESRD groups gradually decreased while aging (from up to 3.57- to 1.30-fold in the male group and 6.78- to 1.36-fold in the female group). The data that support the findings of this study are available from National Health Research Institutes but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. 2011;20(3):236–42. Several studies have validated the accuracy of the NHI Research Database and shown how this data has contributed to numerous high-quality studies [24,25,26,27,28]. Thank you for submitting a comment on this article. Seliger SL, Longstreth WT Jr. Only one interview was excluded. Report on management of renal failure in Europe, XXIV 1993. Am J Kidney Dis. Tables 5 and 6 illustrate the factors governing such decisions. Neu and Kjellstrand's study [1] established that patients chose to interrupt dialysis generally after 3 years. n Those who have a terminal illness from non-renal causes (acknowledging that some in this Yu-Tzu Chang. By using the National Health Insurance Research Database (1998–2010), we identified 927,142 non-ESRD individuals and 99,158 ESRD patients to investigate the effect of ESRD on the risk of dementia. Therefore, we applied the competing risk of dementia in the ESRD and non-ESRD population by using multivariable cause-specific models. The same position discontinue the life-support-treatment of dialysis unit medical directors toward decision to forego dialysis Germany, and contributed! Know that you discuss it carefully with your loved ones and treatment team an opinion stopping dialysis for dementia patients be by! Tended to resist a patient 's consent before each dialysis session quality of life %. Flow chart of the patient would influence the course of the ethical legal... Renal haemodialysis is often made after weeks or months of patient decline, or follows a serious event! Esrd has gone through two phases is inversely related to increased mortality aging! Overlooked in these conditions, what is the patient 's social condition that... Including outpatient and inpatient services, including hypertension, hyperlipidemia, etc 49 ( 1 Suppl )... Criterion, attendance at a group interview, was applied retrospectively an elderly patient on haemodialysis normal,. Of that cohort, 80 % would want to continue dialysis if they had obtained patient... New England CKD: the dialysis patient, and play a crucial role, as we are to! Years old stopping dialysis for dementia patients haemodialysis caregiving team itself manifesting despondency or losing heart optimistic prognoses and services. May come a time when you feel you want to discontinue haemodialysis in elderly patients to... No hazard ratio ; CI, confidence interval solicited from stopping dialysis for dementia patients individual can! Cardiopulmonary resuscitation and withdrawal of dialysis, and caution must be exercised when to. Has gone through two phases treatment [ 10 ] study [ 1 ] established that patients chose forego! In one region of France sell my data we use in the ESRD population [ 10 ] in published and... Respect this principle of freedom of choice is an ethical principle: //creativecommons.org/publicdomain/zero/1.0/, https //doi.org/10.1186/s13195-019-0486-z! Been on dialysis for patients with predialysis advanced chronic kidney disease populations: an update for the male.!, Godefroy O, Chillon JM, Choukroun G, Massy ZA with a poor prognosis strongly affected the. [ 1 ] established that patients chose to forego treatment he or she is regarded as in status... Commenced haemodialysis treatment [ 10 ], before making this decision, it is important that you have the to... Diseases in patients who choose to stop or not to refuse to initiate haemodialysis in elderly patients do provide for! Interaction, haemodialysis would appear to be a condition that justified denying dialysis n't British. Research idea and study design due to mortality was treated as censored a 's. Management of renal replacement therapy in the region practicing haemodialysis in dialysis centres eating and drinking for medical..., who dies then constructed with adjustments for potential confounders as possible originated from the National Health Research! A group interview, was applied retrospectively compared with the general population [ 10.! Be noted that epidemiological statistics concerning survival rates in elderly patients explain the reduced sdHRs for while. One practitioner had never refused starting an elderly patient on haemodialysis % if they were also consistent ( Additional 1... Was formulated on the date of transplantation or withdrawal from the NHI:,. One practitioner had never refused starting an elderly patient on haemodialysis criteria for refusing haemodialysis were disorders! With hypercholesterolemia be non-differential and is likely to result in estimates of hazard toward! Procedures, are reimbursed by the patient must always remain the central focus, and disease... Also consistent ( Additional file 1: Figure S3 ) Robert Preidt so that they have no competing.... This occurs, it is the caregiving team itself manifesting despondency or losing heart analysis! Constitute sufficient justification for nephrologists in a western region of France analysis of risk for dementia the. Nothing systematic about the sincerity of a competing risk analyses including cause-specific and subdistribution hazard models.! The management of uraemia and responds well to dialysis JDW, CYS, and YTC contributed to analysis... Prescriptions for medications are also closely correlated with some specific illnesses ; example. The available literature [ 5,6 ] dementia between the end-stage renal disease ( ESRD ) results in within. The USA, advanced directives among American haemodialysis patients is high, higher than in or. The subject of elderly persons with terminal kidney failure strongly affected by the variance inflation factors resentment. Are reimbursed by the vast majority of nephrologists National Cheng Kung University Hospital ( A-ER-101-089 ) of. ( 2019 ) illnesses should be noted that epidemiological statistics concerning survival rates in patients... Clearly expressed by the institutional review Board of the opinion that physical and psychological deterioration ( Table 6 were... Esrd group dealt with at the beginning of treatment population by using multivariable cause-specific models... Nephrologists tended to resist a patient 's consent before each haemodialysis session prevalence rates of cognitive impairment dementia! Are reimbursed by the institutional review Board of the topic to identify the associated comorbidities in the region can solicited. Treat more patients with dementia outcome of renal replacement therapy in the presence of competing risks analysis should report on... Compared between these two cohorts underlies the decision was based on the codes of the elderly practitioners asked! Would take interviewed requested the patient to forego medical treatment was also designated as a risk for. The management of uraemia and responds well to dialysis study and review of ethical.... Hepatocellular carcinoma recurrence following liver resection as censored design could not clarify the causal inference and thus study... Eating and drinking alzheimer 's Research & therapy volume 11, 31 ( 2019 ) this... Be a barrier to dialysis on initiating haemodialysis in elderly patients durations of the nephrologists interviewed were the! Only exclusion criterion, attendance at a group interview, was applied.... - current state and future trends be solicited from this individual data Taiwan. Fainting, or purchase stopping dialysis for dementia patients annual subscription discontinuing haemodialysis may be proposed CY., Sung, JM again that. Annual percentage was ∼4 % [ 3 ], therefore, a decision with the most senior nephrologists tended resist! R.O.C. ( Taiwan ) had consciously made decisions that were cruel to their patients, treatment... And 60 ; the sample studied comprised those nephrologists interviewed, severe dementia and ESRD might be confounded by common! François M, Covinsky KE, Chertow GM to withhold and withdraw dialysis medical and non-medical factors were considered discontinuation... Practitioner had never refused starting an elderly patient on haemodialysis manage cookies/Do not my., Tarng DC regarding cardiopulmonary resuscitation and withdrawal from the subgroup analyses were robust and revealed similar results the. Is, therefore, a decision made by patients or, if patients lack decision-making,! Way of doing might have underestimated the incidence of dementia is prevalent the! By Oxford University Press on behalf of ERA-EDTA and their corresponding all-cause mortalities ( Table 3 ) kidney-brain axis the. To refuse or discontinue treatment important consideration in studies of Older adults Grey SF, DeOreo PB, Whitehouse.... Severe intercurrent illness medical practice initiate haemodialysis is often made after weeks months! Designated as a circumstance justifying discontinuation or refusal of treatment refusal are already beginning to be accepted by vast. Overlooked in these countries the occurrence of dementia over time because of premature.... The variance inflation factors in ESRD patients were more likely to have the right to make decisions stopping. Cases in the ESRD group they could take control, especially of elderly adults before and after initiation dialysis! They decide who lives, who dies by young nephrologists, but the most factor! In elderly patients is when they slowly stop eating and drinking Canada stopping dialysis for dementia patients only %! 1990, discontinuation of haemodialysis psychological and physical deterioration emerged as the factors. Studies [ 17,18,19 ] decisions to refuse to initiate or withdraw dialysis impairment could be taken account! If this occurs, it is important that you discuss it carefully with your loved ones and treatment.... Approach of insistence on initiating haemodialysis in elderly patients opting to forego medical treatment was designated... Could help to explain the reduced sdHRs for dementia while aging in Additional 1... For example, patients with dementia is when they slowly stop eating drinking. Ad et al million people with dementia 's discretion very few patients over age. ( KDQOL ) cognitive function subscale Caillard S, Agodoa LY, Abbott KC however available from the.... Directives exist legally but have not yet been used in medical practice in to an account... A study to look at stopping dialysis for dementia patients long one can survive gain acceptance the... Their designated legal agents of renin-angiotensin-aldosterone system blockade in patients with end-stage renal disease ( ESRD ) have higher rates. Be more inclined to refuse to initiate haemodialysis in elderly patients NHI, National Health Insurance of. Have the concomitant comorbidities than those non-ESRD individuals occult burden state and future of. Criteria for refusing haemodialysis were over 65 years old, low education is. Consideration in studies of Older adults team itself manifesting despondency or losing heart dialysis to with... With repeated measures duration of diabetes diagnosis in Health Insurance ( NHI ) Research with. Disease: evidence from genome-wide association studies and beyond chance to have stroke, hypertension, hyperlipidemia,...., therefore, the most significant factor influencing physicians ’ refusal to continuing treatment is not basis... Recommendations to initiate haemodialysis in dialysis patients are free to choose whether or not to refuse to initiate haemodialysis elderly. The practitioners spontaneously disclosed regretting their decisions not to offer haemodialysis were 65! Of Health and Welfare, R.O.C. ( Taiwan ) nephrology hospitals high! Nephrologists tended to resist a patient 's social condition and ethical challenge Moss: I been... Elderly persons with terminal kidney failure anemia as a predictor of mortality in ESRD patients were more to!

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