PANEL DE DISCUSION
Dimitrios G. Oreopoulos. Canada
The increasing number of people living beyond age 65 will be one of the most serious social problems of the next century. By the year 2040, 21% of the population of the United States will be over 65, and by the year 2050, 1 in 20 people in the U.S.A. will be older than 85 (1,2).
The increase in the elderly population, along with the improvements and progress in nephrology in general, and dialysis in particular, will lead to an increase in the number of elderly people on dialysis, a trend that has already started and is present in all dialysis units in industrialized/developed countries. In 1990 the median age of ESRD patients on dialysis in the U.S.A. was 61 years. By the year 2000 approximately 60% of ESRD patients will be over 65 years.
The time has come, therefore, for the nephrology community to pay more attention to the problems of elderly patients, both before and during dialysis. To do that, nephrologists must learn the characteristics of geriatric medicine, and cooperate with family physicians, geriatricians and cardiologists, familiarizing themselves with developments in these specialities (1).
· · · · Worldwide, there has been an increase in the number of elderly on dialysis, which is expected to continue over the next few decades. The steepest increase has occurred among those 75 years of age and over. The next three slides show these trends in the United States, Canada and Europe. It is interesting how similar these trends are. Even in the UK that has been accused in the past, the increase is obvious in the 90's.
· This increase is due to a number of reasons, such as: a change in the attitude of nephrologists and referring physicians; aging of the general population; improved survival of the chronically ill; availability of sufficient dialysis facilities; technical improvements that improve dialysis tolerance; the development of various chronic peritoneal dialysis (PD) modalities; and the education of the general public (1,4,5,6).
METHODS OF TREATMENT OF ESRD
· Once the elderly patient has reached the end stage, it seems that dialysis is the only option, except in Norway where 55% of those over the age of 65 receive transplants (3). In all other countries, the percentage of those receiving transplants is less than 5%. The utilization of PD varies among the various European countries.
· This slide shows the utilization of peritoneal dialysis in Canada according to the age groups.
· The choice of dialysis modality is influenced by what is available and the biases and financial interests of the individual nephrologist. When both dialytic modalities are equally available, the choice should be based on individual, medical, social and psychological factors. (1,3,7).
· This slide shows the advantages of peritoneal dialysis for the elderly.
· · · The next three slides show survival of the elderly in comparison with younger groups in the USA, Canada and Europe. In the last slide one can notice the improvement of the survival results over the last decade.
· Kjellstrand expressed the risk of dying from renal failure in comparison to aged matched controls and you can note the significantly lower proportional risk of death for elderly.
These results may improve even further with changes in dialysis technology and policies, along with changes in support therapy (erythropoietin, antihypertensive treatment, etc.) as well as with greater cooperation between nephrologists, geriatricians, family physicians, cardiologists, etc.
Results may be further improved for elderly patients on PD (even those with multiple comorbid conditions) with the use of home nurses (10).
PSYCHOLOGICAL ASPECTS OF THE ELDERLY ON DIALYSIS
· ESRD is a severe illness that requires a change in lifestyle by both patients and the family, especially in the elderly. Common handicaps are a decrease in socioeconomic status, changes in family roles, the restriction of social activities, and sexual problems. A large percentage of these patients have major depressive episodes.
It should be emphasized, however, that although depression is frequent among elderly patients on dialysis, depressed and non-depressed patients do not differ significantly in age.
· Kjellstrand in an earlier study showed (READ).
· In a more recent study Mody et al. from Kjellstrand's team who studied the attitudes among elderly patients on hemodialysis found that 70% felt that life is okay on dialysis compared to younger patients. (Read).
· As a result of these findings one can say that the quality of life among elderly (Read).
· Next slide compares the general health among the two modalities on a scale of 1 to 5.
SOCIAL ASPECTS OF THE ELDERLY ON DIALYSIS
Although most older people live in the community and are cognitively intact and fully independent in their daily activities, a substantial number who are not confined to a major institution report major limitations in activity due to chronic disease.
Often elderly patients are concerned that they will become a burden to their families and prefer to maintain an independent household and to use peer groups for support; also their ability to draw upon past experiences often enables them to adhere to a complex medical treatment better than any other group (14).
An adequate social support system, of which the family unit is the crucial component, is important to the outcome of the elderly patients on any form of chronic dialysis. In home dialysis, such support determines the patient's ability to remain in the community and avoid institutional care. Without strong family support, impaired mental function and physical disability increase the likelihood of institutionalization, and diminish the potential for successful home dialysis.
· Continuous ambulatory peritoneal dialysis (CAPD) performed by trained home nurses provides the elderly patient with a convenient, comfortable and safe means of home dialysis in a familiar environment without reliance on other family members. Having described to you the medical aspects and benefits of dialyzing the elderly I will turn into the ethical issues.
· THE ELDERLY AS A BURDEN TO THE FAMILY
· ETHICAL ISSUES IN THE ELDERLY ON DIALYSIS
· THE ELDERLY AS A BURDEN TO THE FAMILY
With regard to family, we are living now in an environment, at least in the west, where wisdom of old people is not considered an asset and is often challenged by the younger generation. Furthermore, with both husband and wife working, looking after an elderly parent who is on dialysis and has problems with his or her daily activities (and if there is no hope of a substantial inheritance) becomes a burden. Often the interest and the will may be present initially, but after some experience with home or hospital dialysis, along with the thrice weekly trips to the hospital and frequent hospitalizations, family members realize they cannot cope. They often give up, asking for the hospital to take over the care of the patient or trying to have him or her admitted to a chronic care facility. This leads to feelings of isolation and desperation in the patient, and is often the underlying cause for the request for the dialysis to be withdrawn.
· THE ELDERLY AS A BURDEN TO THE HEALTH-CARE TEAM
Although it is the responsibility of the health-care team to look after their patients with equal care and interest, I have often witnessed that the elderly, with their myriad problems and unexpected complications, do not get the care they deserve. Health-care providers should be patient and attend to all their problems, which often are not medical. A team approach with the help of social workers and psychiatrist is very important. Setting realistic goals, which are different than those of younger patients, is also very important. Often, learning about their elderly patient's histories, who they were and what they have achieved in life, can help health-care providers to have increased respect for them.
· THE ELDERLY AS A BURDEN TO SOCIETY
The care of the elderly, and especially those on dialysis, contributes substantially to the increase in health-care costs. Their increasing numbers, lower functional status and multiple significant chronic illnesses necessitate closer monitoring and expanding nursing care. As a result, society, through its legislators, questions the appropriateness of the utilization of expensive health-care technology for this segment of the population. Some, like the former governor Lam of Colorado have gone even further and recommended that a patient's age should be used to ration and limit technically sophisticated treatments, which in turn would lead to a substantial saving (1,2,7).
· The most eloquent voice among the latter is that of Daniel Callahan, who in his book "setting limits" proposes that age, than need, should be the criteria for the provision of limited health-care resources (16). He argues that we should shift our attitudes from aging and the goals of medicine towards the rationing of expensive treatment.
Callahan believes that medicine must refocus its efforts in the elderly away from the curing of disease and the extension of life to an ethic of caring and compassion.
· Specifically concerning dialysis, Callahan writes: "Dialysis represents precisely the kind of technology that should not be sought or developed in the future. It does not greatly increase the life expectancy (an average of only five years) and for most the gain is at the price of a doubtful or poor quality of life and an inability to achieve earlier levels of functioning." I believe this assessment is both arrogant and false. As mentioned before, Kjellstrand and several other authors have shown that elderly patients on dialysis have a particularly high level of life satisfaction but, irrespective of that, when did "an average increase of only five years" become a negligible gain in medicine?
· The next two slides show comparisons of the survival of elderly on dialysis with that of some other disease of the elderly, for which nobody has recommended that our efforts should be stopped.
· FUTILITY AND MANAGED CARE
Recently two other ways with which society tries to handle the burden of health care to the elderly are the concepts of 1) futility and 2) managed care.
I am not surprised that the concept of futility sprang up in our vocabulary during the last 5-10 years, when cost containment became a main concern. Agreeing that providers are not obliged to provide treatments that are deemed futile is the first step in this process. It is difficult to argue against this. However, agreeing on what is futile treatment and who would decide on it is another issue. If the physician is mainly concerned with societal good, and not the patient's interests, it is easier and less painful for the physician to refuse a treatment "because it is futile" rather than "because there is no money." I believe that it is futile to attempt to define futility and that whenever there is a conflict between they physician and the patient's relatives regarding futile treatment the physician should never be confrontational but rather attempt to get the familie's consent using the principles of conflict resolution.
In managed care, where the lowest bidder will be granted the care of a group of patients with a fixed amount of money, I am sure that the elderly, who often require expensive care and referrals to specialists, will be shortchanged, otherwise the health-care provider may not make a profit or even may lose money. This is a convenient way of transferring the responsibility of restricting provision of care from the managed care organization to the provider, and at the same time allowing both parties to make a profit, albeit at the cost of the elderly and other vulnerable groups (18). I have been vindicated in these gruesome predictions when I read the following in a recent editorial (Read).
· PHYSICIANS AND THE PROVISION OF HEALTH CARE TO THE ELDERLY
Physicians play a major role in the provision of care, especially to the elderly. With regard to providing dialysis to the elderly, physicians, consciously or unconsciously, have for years restricted access for various reasons. If this is to be avoided, physicians will have to make a conscious effort to recognize these reasons and avoid them.
· As I have shown in the beginning of my talk over the last 20 years, there has been a continuous increase in the percentage of new elderly patients accepted for dialysis, along with a constant increase in the mean age of new dialysis patients. As long as these curves do not level off, this means that elderly patients were being rejected from dialysis.
· A recent survey on the importance of selection criteria indicate that in the presence of unlimited resources nephrologists are less biased now against accepting the elderly for dialysis, even up to the age of 90 (1,19). Only 10% indicated age as a sole criteria although Kjellstrand indicates that in the case of cost restrictions, the elderly will be the first to be refused treatment (19,20).
· PHYSICIANS, COST CONTAINMENT AND THE ELDERLY WITH ESRD
Although the continuous increase in the elderly dialysis population indicates a decreasing bias on behalf of nephrologists towards dialyzing their elderly patients, recent cost containment concerns have made some physicians (at least in Canada and Europe) conscious of their social responsibilities and on their own they have started recommending that perhaps we should reconsider our position towards accepting the elderly for dialysis (21).
Whereas I accept that physicians have an obligation to optimize the use of public funds and avoid wastage, I do not think that age per se should be used as a criterium for providing such services.
Physicians have a moral obligation to treat everybody equally, independent of age, gender, race, religion, country of origin or political belief (22). When they are hindered in doing so by external factors directly of indirectly applied on them, they have the obligation of acting as their patients' advocates and speaking out on their behalf. The final decision on whether the quality of life on dialysis is acceptable should be left up to the patient, and in this respect a trial of dialysis is appropriate, with the understanding that if things do not work out and the patient wants to discontinue dialysis, his or her wishes will be respected.
If the patient requests that dialysis be discontinued, he/she should not be abandoned and should be cared for to the end, along with his or her family.
· DIALYSIS OF THE ELDERLY - BENEFIT OR BURDEN?
I think that I have shown, and I hope convincingly, that dialysis in the elderly prolongs life, and for a large percentage, this life is of a good quality. I believe that this is a benefit for the patient.
There is not doubt that the elderly, especially those with ESRD, have multiple comorbid conditions that lead to increased hospitalization, referrals to specialists, and an overall increased use in the costs for their management.
If indeed costs are the only things that our society is concerned about, and let us not forget that when I say society I mean all of us, there is no doubt that dialysis in the elderly becomes a burden to society, but in that respect, everybody who is in need becomes a burden to society.
I believe, however, that it is up to us to decide what kind of society we want to be. I think that to earn the title of a civilized and caring society, we must first care for those in need amongst us. Once this becomes a priority, I believe that taking care of the needs of the elderly will not be looked upon as a burden. However, before we, the medical profession, attempt to guide the society in changing its priorities, we have to search our hearts, rededicate ourselves to our oath of service and emphasize in everything we do our commitment to the care of our patients and the primary importance of our relationship with our patients.
· WHAT SHOULD WE DO?
I propose that when we are faced with competent elderly patients with ESRD, we should present them with the bare facts of what dialysis means and can provide, answer all their questions about their quality of life on dialysis and help them make their own decision, which thereafter we should respect. If they are uncertain about their choice, a treatment trial may be appropriate. If the prognosis is grave and we believe that such treatment would be futile, but the patient or his or her relatives insist on that treatment be instigated, we should avoid confronting them.
Instead, we should allow them the necessary time and energy to discuss the reasons behind their decisions and to educate their relatives about the futility of their decision. It takes considerable time, but it is time well spent. I believe also that we have an obligation to educate the public continuously about the rights of elderly individuals to equal justice and dignity. Being elderly does not make a person less of an individual. We have an obligation to be their advocates and to speak out on their behalves against any rationing of treatment. Advocacy for our patients is an ethical principle, as important as beneficence, non-maleficence, justice and respect for the patient's autonomy, and I believe we should inculcate it into our students from the beginning of their training. I see this presentation as my opportunity to advocate for the rights of elderly patients with ESRD.
1. Mignon F, Michel C, Mentre F, Viron B. Worldwide demographics and future trends of the management of renal failure in the elderly. Kidney Int 1993; 43:S18-6.
2. Calkins ME. Ethical Issues in the Elderly ESRD Patient. ANNA Journal 1993; 20:569-71.
3. Mignon F, Siohan P, Legallicier B, Khayat R, Viron B, Michel C. The Management of Uraemia in the Elderly: Treatment Choices. Nephrol Dial Transplant 1995; 10:55-9
4. Henrich WL. Dialysis Considerations in the Elderly Patient. Am J Kidney Dis 1990; 16:339-41.
5. Desmeules M, Schaubel D, Fenton SSA, Mao Y. New and Prevalent Patients With End-Stage Renal Disease in Canada: A Portrait of the Year 2000. ASAIO Journal 1995; 41:230-3.
6. Fenton S, Desmeules M, Copleston P, et al. Renal Replacement Therapy in Canada: A Report From the Canadian Organ Replacement Register. Am J Kidney Dis 1995; 25:134-50.
7. Latos DL. Chronic Dialysis in Patients Over Age 65. J Am Soc Nephrol 1996; 7:37-46.
8. Nissenson AR. Dialysis Therapy in the Elderly Patient. Kidney Int 1993; 43:S51-7.
9. Salomone M, Piccoli GB, Quarello F, et al. Dialysis in the Elderly: Improvement of Survival Results in the Eighties. Nephrol Dial Transplant 1995; 10:60-4.
10. Wadhwa NK, Suh H, Cabralda T, Sokol E, Sokunbi D, Soloman M. Peritoneal Dialysis with Trained Home Nurses in Elderly and Disabled End-Stage Renal Disease Patients. Adv Perit Dial 1993; 9:130-3.
11. Kutner NG, Brogan DJ. Assisted Survival, Aging, and Rehabilitation Needs: Comparison of Older Dialysis Patients and Age-Matched Peers. Arch Phys Med Rehabil 1992; 73:309-15.
12. Kjellstrand C, Koppy K, Umen A, Nestrud S, Westlie L. Hemodialysis of the Elderly. In: Oreopoulos DG, ed. Geriatric Nephrology. Amsterdam: Martinus Nijhoff, 1986.
13. Moody H, Moody C, Szabo E, Kjellstrand C. Are Old Dialysis Patients Happy? Can They Fend for Themselves or Not? XII Intern Congress of Nephrology. Jerusalem, Israel, 1993.
14. Parry RG, Crove A, Stevens JM, Masson JC, Roderick P. Referral of Elderly Patients with Severe Renal Failure: Questionnaire Survey of Physicians. BMJ 1996; 313:446.
15. Michel C, Binci P, Viron B. CAPD with Private Home Nurses: An Alternative Treatment for Elderly and Disabled Patients. Adv Perit Dial 1990; 6:92-4.
16. Callahan D. Setting Limits: Medical Goals in an Aging Society. New York: Simon and Schuster, 1987.
17. Thent RW. A Critique of Using Age to Ration Health Care. J Med Ethics 1993; 1:19-27.
18. Oreopoulos DG. Is It Appropriate to Offer Dialysis to Octogenarians? A Modern Conspiracy? Perit Dial Int 1996. 16:241-2.
19. Pollini J, Teisser M. Undilemme difficilea resoudre: Les malades ages recuses pour la dialyse chronique. Problemes, ethiques ou choix medical? IN: Mignon F, ed. Nephrologie Prospective: Le 3eme age. Paris: Nephrologie 1990 (Suppl): 341-7.
20. Kilnew JF. Selecting Patients When Sources are Limited: A Study of U.S. Medical Directors of Kidney Dialysis and Transplantation Facilities. Am J Public Health 1988; 78: 144-7.
21. Hirsch DG, West ML, Cohen AD, Jindel KK. Experience with Not Offering Dialysis to Patients with a Poor Prognosis. Am J Kidney Dial. 1994; 23:463-6.
22. Nissenson AR. Quality of Life in Elderly and Diabetic Patients on Peritoneal Dialysis. Perit Dial Int 1996; 16:S406-9.