Initiation of Renal Replacement Therapy
Understanding and communicating prognosis Patient-centred decision making “Provision of dialysis should benefit the patient, and not just prolong life” [3] . In South Africa, there are substantial limitations to accessing chronic dialysis [4] . Treatment options are limited in the public sector. Many patients, therefore, are on a conservative pathway, not through choice or medical rec
Understanding and communicating prognosis
Patient-centred decision making
“Provision of dialysis should benefit the patient, and not just prolong life” [3].
In South Africa, there are substantial limitations to accessing chronic dialysis [4]. Treatment options are limited in the public sector. Many patients, therefore, are on a conservative pathway, not through choice or medical recommendation, but through circumstance. However, regardless of dialysis availability, healthcare professionals should address the patient’s personal goals and aims for the future.
Understanding and communicating prognosis
The ability to prognosticate and communicate prognosis is essential [5]. This may be a long process and require frequent repeating. There are a few studies that combine prognostic factors in clinically useful prediction tools [6,7].
Patient-centred decision making
In ideal circumstances, patient-centred decision making should be implemented by a multidisciplinary team [8,9]. It should be a family orientated and culturally appropriate process where the team and patient agree on a specific course of action based on a common understanding of the patient’s treatment goals. It should consider the benefits and harms of the treatment and the likely outcomes. All the possible options should be discussed openly. This should include all dialysis modalities, withholding or withdrawing dialysis and an “opt-out” option for the patient in the future after a trial of dialysis. Access to private medical insurance should also be discussed.
The timing of the decision-making process is important. The Supportive and Palliative Care Indicators Tool (SPICT) [10,11] advises that these discussions should be held at or when:
- Stage 4 or 5 chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) < 30 mL/min/m2 ) with deteriorating health
- There is also strong evidence for using the Kidney Failure Risk Equation (KFRE) to better determine progression to ESKD (kidneyfailurerisk.com) [12]
- Kidney failure complicates other life-limiting conditions or treatment
- Ceasing or changing dialysis modality.
Periodic review of the proposed decision should be included in the plan. The timing of these reviews should be agreed on at the initial interview. The review should include whether dialysis is still benefiting the patient’s personal aims or goals and should be revised after any new critical event (e.g. after a stroke).
The Renal Physicians Association of America suggests that it is reasonable to consider forgoing (not starting or ceasing) dialysis for the following groups of patients [13]:
- There is a condition precluding the technical process of dialysis (e.g. an uncooperative patient with advanced dementia) or the patient is medically unstable (e.g. suffers from profound hypotension).
- A terminal non-renal illness (we acknowledge that some may perceive benefit and choose to undergo dialysis).
- Refusal/discontinuation of dialysis in a patient with decision-making capacity, who is fully informed and making a voluntary choice.
- Patients who no longer possess decision-making capacity and who have previously indicated refusal of dialysis in an advanced care directive, or those whose legal agents/surrogates refuse dialysis or request that it be discontinued.
- Patients with irreversible, profound neurological impairment.
- In the case of children, it may also be appropriate to withhold renal replacement if the family situation is unable to support the child (see paediatric section for more details).
- Patients over the age of 75 years, who have two or more of the following poor prognostic criteria:
- Depend on others for care due to increasing physical and/or emotional and/or mental health problems
- Significant weight loss (> 10%).
- High comorbidity score, e.g. modified Charlson Comorbidity Index score of 8 or greater [14] (see Addendum 1).
- Significantly impaired functional status, such as Karnofsky score < 40 with limited reversibility [15] (see Addendum 2).
- The patient asks for palliative care, or chooses to reduce, stop or have no treatment.
Wearne, N., Krause, R., Davidson, B., and Brennan, F., 2020. Renal palliative and supportive care in South Africa – A consensus statement. African Journal of Nephrology, 23(1), pp.86-107.