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Nephrologists Unprepared for End-of-Life Decisions

Physicians who were more comfortable making the decision to withdraw dialysis were usually older and had more years of experience than those who felt less confident.

REVIEWED BY SARA N. DAVISON, MD, FRCP, MHSc, BHSc

Sixty percent of nephrologists do not feel well prepared to make the decision to stop dialysis in kidney disease patients nearing the end of life, according to a study in the Clinical Journal of American Society of Nephrology.

Nephrologists in the study who were more experienced and more familiar with the formal guidelines for end-of-life decision making — developed by the Renal Physicians Association (RPA) and the American Society of Nephrology (ASN) — were better prepared, concluded the study led by Sara N. Davison, MD, FRCP, MHSc, BHSc, of University of Alberta, Canada.

The researchers analyzed responses to a questionnaire regarding end-of-life decision making by 260 American and Canadian nephrologists. According to the survey, 39% said they felt “very well prepared” to make the decision to withhold or withdraw dialysis in patients with kidney disease nearing the end of life. Physicians who were more comfortable in making that decision tended to be older and had more years of experience than those who felt less confident. The well-prepared physicians also had more experience in withdrawing patients from dialysis: 5.6 times in a year versus 3.8 times a year for those who felt less prepared.

AWARENESS OF GUIDELINES KEY
Another key factor was awareness of the RPA/ASN guidelines. Seventy percent of nephrologists comfortable with end-of-life decision making were familiar with the guidelines compared with 52% of those who were less comfortable.

One important difference was in the preparation to stop dialysis in a patient who had developed severe dementia. Two-thirds of well-prepared physicians said they were likely to stop dialysis in this situation compared with 50% of nephrologists who had rated themselves less prepared. Handling of other situations covered by the guidelines (eg, a permanently unconscious patient or a request by a patient who was competent to make such a request) was similar between groups.

Despite continuing technological improvements in care, >80,000 chronic dialysis patients die each year in the United States, with an annual mortality rate of up to 25% per year. Increasingly, kidney specialists play a central role in making decisions, along with patients and/or families about withholding or withdrawing dialysis.

“Unfortunately, these discussions often occur late in illness, when patients are suffering and are often too ill to make decisions for themselves,” said Dr. Davison. “In fact, patients often do not know they have the option to withdraw from dialysis, while others erroneously believe that their physician would not support such an option.”

EXPERIENCE TRUMPS EDUCATION
The results showed that clinical experience is more important than education in preparing nephrologists to deal with these complex decisions. “This is not surprising, given that end-of-life care is not well addressed in nephrology specialty training programs,” Dr. Davison said.

Many health professionals believe that end-of-life discussions may destroy hope for dialysis patients. “In contrast, our recent research suggests that end-of-life discussions through the provision of timely, appropriate information can positively enhance rather than diminish patients’ hope,” said Dr. Davison. “Dialysis patients prefer that these conversations happen early in the illness and expect their physicians to initiate and guide the discussion — even if for some patients, much of the discussion occurs with family members, outside the patient-physician relationship.”

Sara N. Davison, MD, FRCP, MHSc, BHSc, is assistant professor, division of nephrology, at the University of Alberta, Canada. She may be reached at sara.davison@ualberta.ca.

Davison SN, Jhangri GS, Holley JL, Moss HS. Nephrologists’ reported preparedness for end-of-life decision-making. Clin J Am Soc Nephrol. Published ahead of print on Sept. 3, 2006 as doi: 10.2215/CJN.02040606.
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