chapter 7 dialysis for chronic renal failure

Chapter 7

Dialysis forChronic Renal Failure

CONTENTS

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ....249Description of Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..................250

Renal Failure: The Need for Treatment . . . . . . . . . . . . . . . . . . . . . . . . .........250Dialysis procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..................251Treatment Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...................255Choice of SRD Treatment Modality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ...255

Utilization and Cost of Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......256Utilization of Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...256Cost of Medicare’s ESRD Program . . . . . . . . . . . . . . . . . . . . . . . . . . ...........257

Outcomes of Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...................259Clinical Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...259Psychosocial Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . ......................261

Making Decisions About Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......262Decisions About Initiating Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......264Decisions About Stopping Dialysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......264Decisionmaking procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..266Ethical ssues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......266Legal Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......................268

Findings and Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........ .. ....268Chapter p references. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...............269

BoxesBox Page7-A. Treatment for ESRD in the United Kingdom. . . . . . . . . . . . . . . . . . . . . . .. ...2637-B. The Earle Spring Case .

Figure No.7-1. Hemodialysis . . . . . . . . .7-2. Arteriovenous Fistula in7-3. Continuous Ambulatory

Table No.7-1. Functions of the Kidney

Chronic Renal Failure . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

FiguresPage

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253the Arm of a Hemodialysis Patient . .............253P e r i t o n e a l D i a l y s i s . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 5 4

TablesPage

and Their Alteration in. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

7-2. Medicare ESRD Program Enrollment by Age, 1978-84 . . . . . . . . . . . . . . . ....2567-3. ESRD Population by Type and Place of Dialysis, 1980-85 . ...............2577-4, Medicare Reimbursements by Enrollees and Per Capita Reimbursements

for People With ESRD, 1974-84 . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..........2587-5. Medicare ESRD Dialysis Patient Survival by Age and Cause

of Renal Failure, 1980-84 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..............259

Chapter 7

Dialysis for Chronic Renal Failure1

INTRODUCTION

Individuals with end-stage renal disease (ESRD)would die within a few weeks or months if notsustained by some form of dialysis therapy or akidney transplant. Nearly 91,000 Americans cur-rently receive some form of dialysis (43). As re-cently as the 1960s, the scarcity and high cost ofresources made treatment of chronic renal fail-ure largely unavailable and inaccessible. Treat-ment was limited to the affluent and the hand-picked. So-called ‘(God committees” composed ofhealth professionals and community leaders se-lected patients on the basis of criteria that includedage, race, sex, family responsibilities, employmentand financial status, and “social worth. ” Patientsyounger than 15 or older than 45 were routinelydisqualified for treatment.

The Federal Government’s commitment in 1972to cover the catastrophic cost of treatment forESRD through Medicare was a pivotal event thathas remained a touchstone in subsequent debatesabout providing expensive medical care for spe-cific groups of patients. Medicare’s ESRD program,enacted into law (Public Law 92-603, Sec. 2991)in 1972 and initiated in 1973, is the only Federalprogram that provides almost complete coveragefor a catastrophic illness (5). It is at once a force-ful reminder of the problems that may exist with-out Federal intervention and of the problems thatmay arise as a result of intervention.

Largely as a result of the ESRD program, dialy-sis and renal transplantation are now availableto virtually all Americans in need, without regardto age, social status, or ability to pay. Followingthe program’s implementation, there occurredrapid expansion of treatment facilities and per-sonnel and significant advances in dialysis andtransplantation technologies (25). Not surprisingly,the number of patients being treated for ESRD

1OTA acknowledges the important contribution in the prepara-tion of this chapter of Nancy B. Cummings, M. D., Associate Direc-tor for Research and Assessment, National Institute of Diabetes, Diges-tive and Kidney Diseases.

increased dramatically. Today, the old problemof access to ESRD treatment has been replacedby one of tremendous public cost. The currentcost of providing benefits to ESRD Medicare ben-eficiaries is about $2.1 billion per year and grow-ing (41).

People over age 65 are now the fastest growingsegment of the dialysis population served by Medi-care’s ESRD program, with an average annualgrowth rate of 15 percent in recent years (40).In 1974, people over 65 who were eligible for ESRDbenefits by virture of Medicare enrollment madeup less than 5 percent of the average annual en-rollment (5); by 1979, patients over 65 accountedfor over 20 percent and by 1984, patients over65 accounted for over 25 percent of Medicare’sESRD program enrollees (40).

The unanticipated growth in ESRD program ex-penditures and the shifting demographic compo-sition of the dialysis population have heightenedconcerns among some people that dialysis is be-ing overused, that is, public resources are beingmisallocated, and/or dialysis treatment is beingwasted on some patients for whom the benefitsare questionable. The U.S. experience with dialy-sis is frequently cited by those who wish to warnagainst excessive growth in other disease-specificbenefit programs or overuse of other life-sustain-ing technologies.

Because dialysis is usually life-sustaining, avail-able, and currently reimbursed through Medi-care’s ESRD program, the dilemmas aboutwhether to use dialysis in individual patients oftencenter around the impact treatment would haveon the patient’s quality of life. Chronic dialysis im-poses a strict regimen that demands time, limitstravel, and imposes strict dietary requirements.Complications and frequent periods of illness andhospitalization are common. Still, most patientswho accept chronic dialysis adjust successfullyand are able to carry on their family and work

249

250 ● Life-Sustaining Technologies and the Elderly

roles. Some dialysis patients have survived formore than 20 years.

Only limited information is available about howelderly patients adjust to chronic dialysis. How-ever, the greater likelihood that elderly people willhave comorbidities or reduced social responsibil-ities, compared with younger people, suggests thatthere may be important age-related differencesin elderly patients’ physiological and psychosocialresponses to chronic dialysis. One study foundthat older patients generally reported a high de-gree of life satisfaction while undergoing chronicdialysis (49). Another study found, however, thatwithdrawal from dialysis was the most commoncause of death in elderly dialysis patients, account-ing for 40 percent of all deaths (compared with22 percent for all ages) (16). The high rate of dis-

continuance may occur because the factors thattrigger the decision, such as multiple underlyingdiseases, are more common and occur earlier inolder dialysis patients than in younger ones (16).

While problems of access to ESRD treatmentand personal financial hardship have been ad-dressed to a very great extent through Medicare’sESRD program, fundamental problems related todecisionmaking for individual patients and relatedconcerns remain. This chapter examines ESRD inthe elderly population, the use, cost, and efficacyof various types of dialysis, the patients’ experi-ence, and how treatment decisions are made. Italso discusses patient selection criteria and theinfluence of reimbursement on treatment patternsand quality of care for elderly patients.

DESCRIPTION OF DIALYSIS

Renal Failure: The Need for Treatment

Healthy kidneys regulate the body’s internalenvironment of water and salts and excrete theend products of the body’s metabolic activities andexcess water (as urine). They also produce andrelease into the bloodstream hormones that reg-ulate vital functions including blood pressure, redblood cell production, and calcium and phospho-rus metabolism.

Impaired renal function, depending on its causeand severity, may affect any or all of these proc-esses (see table 7-l). Impaired renal function maybe due to problems in the kidney or to diseasein other organs. It may be caused by pathologicalproblems or normal, age-related processes.’ Itmay be acute or chronic and either minor or life-threatening. All these distinctions are important

‘Normal aging, in the absence of disease, is associated with aprogressive loss of renal function beginning early in adulthood. Onaverage, adults lose 7 to 8 percent of renal function per decade,but the individual variability in age-associated loss of renal functionis very great. Some people lose as much as 60 to 70 percent betweenthe ages of 30 and 80, and others experience little or no age-associatedloss of renal function. Even when extreme, the normal changes inkidney function associated with aging do not significantly interferewith the normal volume and composition of body fluids or normallevels of waste products. Normal, age-related changes in renal func-tion are significant, in general, because elderly individuals have lowerreserve and are at heightened risk for developing renal failure asa result of disease or injury.

determinants of prognosis and appropriatetreatment.

When a person’s loss of renal function is so se-vere as to be incompatible with life, the patientis said to be in renal failure. Renal failure maybe either acute or chronic.

Acute renal failure is the sudden, potentially re-versible loss of renal function. It may be causedby any of several hundred diseases, by drugs thatare toxic to the kidneys, surgery, trauma, reduc-tion or cessation of blood flow (i.e., ischemia) tothe kidneys, or by obstruction of urine flow (13,22). Many patients in acute renal failure regainnatural function of the kidney after temporarysupport by dialysis. Others die from the under-lying disorder that caused the kidney to fail. Insome patients, acute renal failure is the precur-sor to chronic renal failure.

Chronic renal failure is irreversible, oftenprogressive loss of kidney function. It can becaused by any of a large number of known andunknown factors, including immunological, con-genital, or infectious diseases, or trauma to thekidneys. By far the most common cause of chronicrenal failure among elderly dialysis patients inMedicare’s ESRD program is hypertension (withheart and renal diseases). other less common

Ch. 7—Dialysis for Chronic Renal Failure • 251

Table 7-1.— Functions of the Kidney and Their Alteration in Chronic Renal Failure

Function Change in chronic renal failure

Excretion of water . . . . . . . . . . . . . . . . . . . . . . . . Well-preserved in early chronic renal failure, progressively reduced in late chronicrenal failure.

Excretion of water-soluble compounds . . . . . . Varies with the compound; in general, progressively reduced as chronic renalfailure progresses.

Production of erythropoietin (stimulates redblood cell formation). . . . . . . . . . . . . . . . . . . . Progressively reduced but not usually to zero; moderate to severe anemia.

Production of 1.25- and 24.25-hydroxychole-calciferol, the active forms of vitamin D . . . Reduced in moderate to severe chronic renal failure—reduced blood calcium

and tendency to bone disease.Production of renin —hormone which helps

to maintain blood pressure and conservesodium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Often increased—contributes to high blood pressure of chronic kidney disease;

removal of both kidneys (to cure this) may cause low blood pressure,Production of prostaglandins and intrarenal

hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Uncertain what part changes in secretion of such hormones play in producingthe symptoms of acute and chronic renal failure.

SOURCE, D N S. Kerr, “Renal Dlalvsis: Techniques and Cllnical Applications,” The Oxford Companion to Medic/ne, J. Walton, P.B. Beeson, and R.B. Scott feds ) (Oxford,England: Oxford University Press, c 1986)

causes of chronic renal failure in elderly peopleare glomerulonephritis, diabetic nephropathy,polycystic kidney disease, and pyelonephritis (1).

As defined in Medicare regulations, ESRD is the“stage of chronic renal impairment that appearsirreversible and permanent, and requires a regu-lar course of dialysis or kidney transplantationto maintain life” (4). ESRD, with an accompany-ing syndrome called uremia (i.e., the symptomatic

phase of renal failure), affects almost every sys-tem of the body, including the cardiovascular, res-piratory, endocrine, central and peripheral nerv-ous systems, the gastrointestinal tract, blood cells,skin, and bones. The symptoms often are so gen-eral that a diagnosis of kidney disease may notbe clear. People experience an overall sense of feel-ing poorly, and they may have difficulty pinpoint-ing the source of their malaise. The scientificunderstanding of all the ramifications of disordersof the kidneys is limited.

Disordered kidney function may be detected bysimple laboratory tests such as urinalysis, meas-urement of blood chemistries (urea, creatinine,electrolytes, calcium, and phosphorus), and by de-termining the kidney’s ability to clear standardsubstances from the blood.

Dialysis Procedures

ESRD can be managed by renal dialysis orreversed by a successful kidney transplant froma living or cadaveric donor (23). In special cases,

other newer technologies such as hemoperfusion,hemofiltration, hemodiafiltration, and plasmaphe-resis may be used (1) (also see app. C, “Future De-velopments in Life-Sustaining Technologies”).

For some patients, kidney transplantation is thepreferred treatment. A successful kidney trans-plant can restore a patient to good health and anearly normal lifestyle. The best results are ob-tained when the organ donor is a living, relateddonor, although good success is also achieved withcadaver kidneys.

Unfortunately, while transplantation is an at-tractive solution in principle, there are manydifficulties in its implementation, especially thesevere shortage of appropriately matched donor

Photo credit Edmund G Lowrie, National Medical Care, Inc

This 83-year-old woman has been on dialysisfor 5 years.

252 Ž Life-Sustaining Technologies and the Elderly

kidneys (25). In addition, life-long immunosuppres-sive therapy, necessary to prevent rejection of thedonor organ, has many deleterious effects. Be-cause of these and other problems, kidney trans-plantation is not at present a realistic option formost ESRD patients. In 1985, only 9 percent ofall ESRD patients received a transplant (42).

Kidney transplants are seldom performed inelderly people. In 1985, only 56 (1 percent) of the6,938 kidney transplants performed in the UnitedStates were performed in patients aged 65 to 74years, and only 3 were performed in patients 75years and older (46). This apparent age-based ra-tioning of kidney transplantation is usually ex-plained on medical grounds. In particular, personswith vascular diseases (e.g., arteriosclerosis) areconsidered poor candidates for transplant surgery,and vascular diseases are common among elderlypersons (13). Another medical factor that weighsagainst performing kidney transplants in someelderly persons is that they have multiple illnesses,which increase the risk of serious complications.Another serious problem is that age-related andother decreases in immune function heighten therisk of infection, especially with the administra-tion of immunosuppressive agents that must beused to prevent rejection of the transplantedkidney.

How many elderly people might benefit fromkidney transplantation if more donor kidneyswere available is not known. At present, however,renal dialysis is the only widely used ESRD treat-ment for elderly persons. Therefore, renal dialy-sis is the focus of this chapter.

The term dialysis refers to any process in whichthe components of a liquid or solution are sepa-rated on the basis of the selective movement ofdifferent kinds of molecules through a semiperme-able membrane. In the case of renal dialysis, im-purities are separated from the blood and passedinto a special fluid called the “dialysate” (or dialy-sis fluid) through a natural or artificial membrane.The movement of molecules through the mem-brane is caused by differences in concentrationsof salts and toxic waste products in the blood andin the dialysate. Contact between the blood anddialysate is repeated many times, and the trans-fer continues until the two solutions have identi-cal concentrations of the affected substances.

Other components of the blood, like proteins andcells, cannot pass through the membrane and areretained in the blood.

The effectiveness of dialysis depends on bothits duration and efficiency. The dialysis fluid,which is made up of the physiologically normalelectrolytes found in blood plasma, is selectedaccording to the approximate eventual composi-tion desired in the plasma. When dialysis proceedstoo rapidly, it may cause symptoms such as pain-ful cramps or problems with blood volume. Be-cause the specific treatment is determined basedon experimentation, rather than theoretical knowl-edge, dialysis is said to be an “empirical” therapy.

Dialysis offers an effective artificial mechanismfor performing kidney functions. Two main typesof dialysis are available: 1) hemodialysis, and 2)peritoneal dialysis (including several variants ofthe latter).

Hemodia lys i s

Hemodialysis is the oldest, most prevalent meth-od of dialysis, and it is used today by the vastmajority of ESRD patients in this country. It is thestandard against which newer methods are judged,The first hemodialysis machine was developed inthe Netherlands by Wilhelm Kolff during WorldWar II, This “artificial kidney” and modificationsof it permitted the first successful attempts to sus-tain patients with acute renal failure (l). Not untilthe 1960s, however, were there hemodialysis pro-cedures to allow long-term maintenance dialysisof patients with chronic renal failure (l).

The process of hemodialysis involves pumpingblood out of a patient’s body into a dialyzer whereimpurities are removed, then returning the bloodto the patient’s body (see figure 7-1). For mostESRD patients using hemodialysis, treatments arecarried out three times weekly for a duration of3 to 5 hours each time. Some patients require morefrequent hemodialysis, while some patients withsignificant residual kidney function can manageon fewer treatments per week. Hemodialysis maybe conducted in a hospital, freestanding dialysiscenter, or in the patient’s home.

Originally, hemodialysis required a new arterialand venous cut-down to obtain access to the pa-tient’s bloodstream for each dialysis treatment.

Ch. 7—Dialysis for Chronic Renal Failure . 253

Figure 7-1.- Hemodialysis

—\

from proportioning system patient

Blood is taken from the arterial tube and pumped throughthe hollow-fiber disposable dialyzer before returning throughan air trap to the patient. Dialysis fluid flows in the oppositedirection from a proportionating system, which makes it fromwater and concentrate. A number of safety devices (notshown) monitor the temperature, flow, and pressure of thedialysis fluid and the presence of air bubbles in the bloodstream.

SOURCE: D N.S. Kerr, “Renal Dialysis: Techniques and Clinical Applications, ”The Oxford Companion to Medicine, J. Walton, P.B. Beeson, and R.B.Scott (eds,) (Oxford, England: Oxford University Press, @ 1988).

The use of maintenance hemodialysis for patientswith chronic renal failure was not possible untila Teflon arteriovenous shunt was developed byScribner and his coworkers at the University ofWashington in the early 1960s (l). Today, thestandard blood access system for hemodialysis in-volves a surgically created connection betweenan artery and vein known as an arteriovenousfistula (see figure 7-2). Access to the fistula, whichis usually in the forearm, is obtained by needlepuncture. Developed in 1966, the arteriovenousfistula resolved problems that plagued patientswith the arteriovenous shunt (i.e., clotting and in-fection) and offers a more permanent solution.Subsequent developments and refinements in thefistula have resulted in shorter dialysis time, in-creased safety, greater comfort, and economy. Forpatients whose veins do not permit the creationof a fistula, a variety of grafts are now possible;however, the “native” arteriovenous fistula is con-

Figure 7-2.— Arteriovenous Fistula in the Arm ofa Hemodialysis Patient

Arterial blood flows through the surgically created fistula intoa superficial vein into which needles are inserted in the ap-proximate direction of the arrow, identifying the cephalic vein.

SOURCE: D.N.S, Kerr, “Renal Dialysis: Techniques and Clinical Applications,”The Oxford Comparrlon to Medicine, J. Walton, P B. Beeson, and R.B.Scott (eds.) (Oxford, England: Oxford University Press, ? 19S6)

sidered “the gold standard of blood access” (1).Consequently, one of the most important meas-ures in the management of patients with chronicrenal failure before they require dialysis is to pre-serve the forearm vessels so these can be usedto develop a fistula when required (32).

Dialyzers consist of three parts: a compartmentfor the blood, a compartment for the dialysate,and a semipermeable membrane separating thetwo (30). The three principal types of dialyzers—hollow fiber, coil, and parallel plate-differ essen-tially in how these basic parts are arranged (30).All three types are described by manufacturersas “single-use disposable, ” but in fact are oftenreused (30). This practice of reprocessing and re-use, possible since the 1960s, has become wide-spread, but it remains controversial.3

Dialysate is usually prepared by diluting a com-mercially available concentrate with treated tapwater. The specific composition of the dialysatereflects the needs of the individual patient andthe choice of the physician.

3In the late 1970s, there was a strong patient movement againstdialyzer reuse in the United States, and the Senate Special Commit-tee on Aging held hearings on the subject and produced a staff re-port on the subject (38). The effect of Federal policies on the prac-tice of dialyzer reuse was reviewed in an OTA case study (30~. Reuseis now very widely practiced worldwide (l). Under the 1987 budgetreconciliation, the U.S, Department of Health and Human Servicesmust establish, by Oct. 1, 1987, standards and conditions for safeand effective reuse and reprocessing of dialyzers (37).


Peritoneal Dialysis

The second major form of renal dialysis is peri-toneal dialysis. First applied successfully in thetreatment of acute renal failure in the late 1940s,peritoneal dialysis is a relatively simple techniquewhose use has increased for both chronic andacute care since the mid-1960s (l).

Peritoneal dialysis uses the patient’s peritoneum(the semipermeable membrane surrounding theabdominal organs and lining of the abdominalcavity) to perform dialysis inside the patient’sbody. The standard blood access device is a per-manent indwelling catheter with a long sub-cutaneous tract placed in the patient’s abdomen.Sterile, warmed dialysis fluid is infused via thecatheter into the patient’s peritoneal cavity, al-lowed to remain there the prescribed length oftime, then drained out along with the dissolvedwaste products, discarded, and replaced withfresh fluid. This cyclical process is continued forthe appropriate number of instillations andremovals. Solute removal occurs by diffusionfrom the blood in the peritoneal capillaries to thedialyzing solution. Solute removal depends on fac-tors such as the dialysate flow rate, temperature,and pH. Fluid removal is by osmosis (l). Althoughperitoneal dialysis is much slower than hemodial-ysis, the same degree of correction occurs pro-vided that longer peritoneal treatments are used.

Depending on the locale and timing of the pro-cedure, chronic peritoneal dialysis may be inter-mittent (IPD); continuous cycling (CCPD); or contin-uous ambulatory (CAPD). Continuous peritonealdialysis methods are typically used in the patient’shome, while intermittent peritoneal dialysis is usu-ally performed in a center or hospital.

Intermittent peritoneal dialysis involves the useof a machine to deliver sterile dialysate to the pa-tient’s peritoneal cavity and, after the prescribeddwell time, to remove the spent dialysate. Theequipment is based on either a cycler that oper-ates by gravity, a pump, or, in older equipment,a reverse osmosis process. Intermittent peritonealdialysis is usually carried out for 10 to 12 hours,3 nights weekly. The main problem with this tech-nique is that as a patient’s residual renal functiondeclines, he or she require’s longer treatmenttimes.

CAPD, a technique of portable self dialysis in-troduced in 1976, affords patients relative free-dom and control over their own care, because itrequires no machine and, often, no assistance (seefigure 7-3). Self-care CAPD patients empty a 2-literbag of dialysate into their peritoneal cavity andthen proceed with their usual activities for thenext 4 to 8 hours or overnight. At the end of thedwell time, the dialysate is drained into the emptybag, detached, and replaced by a fresh bag. The

Figure 7-3.—Continuous AmbulatoryPeritoneal Dialysis (CAPD)

A sealed bag containing 2 liters of dialysis fluid is firstemptied into the peritoneal cavity, then wrapped up andstowed in a pouch while the patient walks around, and finallyhung below the abdomen to drain out the used fluid. The oldbag is then changed for a full new one.

SOURCE: D.NS, Kerr, “Renal Dialysis: Techniques and Clinical Applications, ”The Oxford Companion to Medicine, J. Walton, P.B. Beeson, and R.B.Scott (eds.) (Oxford, England: Oxford University Press, C 19S6).

Ch. 7—Dialysis for Chronic Renal Failure ● 255

process of drainage, disconnection, connection,and infusion takes 30 to 45 minutes. The proc-ess is repeated three to five times daily, 7 daysa week. Sterile technique must be maintained.CAPD has undergone an astonishingly rapid in-crease in use worldwide. It is now the most popu-lar form of peritoneal dialysis and the most com-mon form of home dialysis, accounting for over13 percent of all dialysis patients in the UnitedStates (46). Apart from possible complications, onemain problem with CAPD is that the patient haslittle or no respite from continuous treatment,

CCPD is a combination of intermittent peritonealdialysis and CAPD that involves the use of a ma-chine to cycle dialysate in and out of the peritonealcavity automatically overnight and ambulatoryperitoneal dialysis during the day (6). Typically,the dialysate is instilled into the peritoneal cavityin the morning and remains there until connec-tion to the dialysis machine in the evening. CCPDreduces the need to make bag changes during theday and, by reducing the number of connectionsto a machine, may also lessen the risk of peritoni-tis (inflammation of the peritoneum).

Treatment Settings

The choice of treatment setting is closely relatedto the type of renal dialysis to be used. Both set-ting and type of dialysis depend on the patient’smedical condition, ability to participate in care,level of support that the patient has available athome, resources in the community, and patientand caregiver preferences. Patients in acute re-nal failure are treated in hospital inpatient facil-

‘ ities, often in an intensive care unit (lCU). Patientswith chronic renal failure can be treated in anICU or a hospital inpatient facility, but if they aremedically stable, they can receive dialysis in anoutpatient facility (either a hospital-based out-patient unit or a freestanding dialysis center) orat home (1).

Institutions that provide outpatient dialysis forpatients with chronic renal failure are divided byMedicare’s ESRD program into two categories:hospital outpatient units and freestanding dialy-sis centers (l). Hospital outpatient dialysis unitsuse the existing administrative structure of thehospital and are able to offer the usual range of

hospital services, including diagnostic, therapeu-tic, and rehabilitative services. Freestanding dial-ysis centers provide staff-assisted outpatient di-alysis but do not provide inpatient services (suchcenters usually contract with hospitals for neces-sary inpatient hospital services). More than 58 per-cent of the 1)558 institutions approved to provideoutpatient chronic dialysis services in the UnitedStates are freestanding facilities (45).

Home dialysis involves training the patient anda family member, or in some cases a paid dialysishelper when a family member is not available, inorder to assist the patient with dialysis at home(3). Home hemodialysis training takes from 3weeks to 3 months, and home peritoneal dialysistraining takes 1 to 2 weeks (1). Home dialysis givespatients with chronic renal failure a measure ofindependence and often reduces the cost of per-sonnel (l). In general, however, home dialysis re-quires more patient initiative, responsibility, andbetter health. Home dialysis patients, because theyare relatively healthy, have fewer hospitalizationsthan other dialysis patients and their annual to-tal costs tend to be lower (39).

Home dialysis requires a range of support serv-ices on an ongoing basis. The patient should re-ceive regular medical followup from a physician(usually monthly). Arrangements must be madefor provision of supplies and maintenance and re-pair of equipment. Ongoing social work support,vocational rehabilitation services, and nutritioncounseling are also important. The patient alsomust have contacts with appropriate members ofa dialysis unit in case of an emergency. A nurseshould be available on call at all times to answerquestions or to respond in an emergency. In addi-tion, self-care patients and their family membersmust be prepared for medical or mechanical emer-gencies.

Choice of ESRD Treatment Modality

In general, the least restrictive ESRD treatmentmodality that is medically appropriate should bethe first choice. Thus, a chronic renal failure pa-tient who is medically stable, instead of being con-fined to the hospital as an inpatient, should prob-ably receive maintenance dialysis at a freestandingdialysis center or hospital outpatient unit. Simi-

256 • Life-Sustaining Technologies and the Elderly

larly, a patient capable of home dialysis should Sometimes decisions about ESRD treatment mo-be allowed that option because of the greater free- dalities are limited by the availability of resources.dom it permits. Home dialysis places great respon- Kidney transplantation, for example, depends onsibility on the patient. This is especially true for the availability of a living, related donor or ca-CAPD, which requires that the patient perform daver kidney. Given the present shortage of donorfour or five treatments daily with meticulous at- kidneys, transplantation is not always an avail-tention to sterile technique (34). able option.

UTILIZATION AND COST OF DIALYSIS

Utilization of Dialysis

Medicare’s ESRD program covers 93 percent ofall patients with chronic renal failure in the UnitedStates (9))

4 and has made treatment for ESRDavailable to an increasing number of elderly andother Americans (see table 7-2).

In 1985, Medicare’s ESRD program served a to-tal of 90)621 dialysis patients and there were 6,938transplants (46). 56 Almost 31 percent of all dial-ysis patients in the Medicare ESRD program wereover the age of 65 (46). Virtually all ESRD patientswho are elderly when treatment is initiated areon dialysis.

The percentage of new dialysis patients who areelderly has increased faster than any other agegroup, with annual percentage increases from

4Persons covered by the armed services or by certain State orprivate insurance programs are exceptions (35).

The total number of ESRD patients is not equal to the numberof transplant patients plus the number of dialysis patients becausedialysis patients may receive a transplant, a patient may receive morethan one transplant, and a transplant patient may be returned todialysis if the graft fails.

6The Veterans Administration, which has a high proportion ofelderly male patients, had 3,327 dialysis patients in 1985 (40).

1980 to 1984 of 11.7 percent for patients age 65to 74 and 20.7 percent for patients over 75 (40).As evidence has accumulated that many elderlypatients tolerate dialysis well and have a reason-able quality of life, more physicians recommendthe therapy and more patients are willing to try it.

While elderly patients are undergoing dialysisin increasing numbers, they have not receivedtreatment at the same rate as younger people. In1979, while 80 percent of the patients age 25 to45 at risk to die of uremia entered dialysis, only30 percent of patients at risk over age 65 and just6 percent of patients over age 75 did so (16).

The proportion of elderly ESRD dialysis patientswill probably continue to increase for sometime.This prediction is based on the aging of the U.S.population and the expectation that cadaver kid-neys will become more readily available to youn-ger ESRD patients (l).

One important implication of the increased en-rollment of elderly persons in Medicare’s ESRDprogram is an increasing proportion of patientswith vascular and other comorbid conditions.Such conditions increase morbidity and reduce

Table 7=2.–Medicare ESRD Program Enrollment by Age, 1979-84

Averageannual 1983-84percent percent

1979 1980 1981 1982 1983 1984 increase increase

Total. . . . . . . . . . . . ..54,428 61,899 70,435 77,886 86,499 92,770 11.3 7.2

Age:Under 25 years. . . . . 4,145 4,552 5,023 5,406 5,817 6,025 7.8 3.625 to 44 years. . . . . . 15,325 17,108 19,745 21,694 24,070 26,070 11.2 8.345 to 64 years. . . . ..23,561 26,351 29,844 32,773 35,330 36,991 9.4 4.765 years or over. . . . 11,397 13,688 15,823 18,013 21,282 23,684 15.8 11.3

SOURCE: U.S. Department of Health and Human Services, Health Care Financing Administration, Bureau of Data Manage-ment and Strategy, Research Report: End-Stage Renal Disease, 1985 (Washington, DC: U.S. Government PrintingOffice, in press, 1987).

.


survival among patients receiving dialysis. Fur-thermore, since patients with such conditions aremore likely to be hospitalized than patients with-out such conditions, their per capita costs are likelyto be higher. It is uncertain whether all the pa-tients with diabetic ESRD and all the elderly pa-tients who might benefit from dialysis are beingreferred.

Growth in the overall U.S. ESRD dialysis popu-lation between 1980 and 1984, is shown in table7-3. Growth in the overall population averagedapproximately 10 percent per year. Growth in thenumber of patients using CAPD averaged almost37 percent per year.

Cost of Medicare’s ESRD Program

The economic burden of dialysis and kidneytransplantation is great for the U.S. health caresystem and for patients and their families.Through Medicare, the Federal Government bearsabout 80 percent of the costs of treatment forESRD. In 1984, ESRD beneficiaries representedless than one-third of a percent of all Medicarebeneficiaries, and accounted for almost 3.2 per-cent of total Medicare expenditures (Parts A andB) (47)40). The costs of ESRD treatments not borneby Medicare are paid by private insurance, Med-icaid, Federal programs such as those of the Vet-erans Administration, and/or personal resources.

The rapidly escalating expenditures of Medi-care’s ESRD program have been well documented

(see table 7-4). In 1974, Medicare’s ESRD programexpenditures were $229 million for 16,000 bene-ficiaries. By 1984, there were 92)770 beneficiariesand annual program expenditures had reachedalmost $2 billion (40).7 This escalation in aggre-gate Medicare expenditures for ESRD was not an-ticipated when Congress established the ESRD pro-gram in 1972, According to some observers, thecost figures Congress was given in 1972 were un-reasonably low and quite misleading (25,29).

Because of the extraordinary costs of the ESRDprogram, Congress has sought to limit the expend-itures through two laws: 1) the ESRD ProgramAmendment of 1978 (Public Law 95-292), and 2)the omnibus Budget Reconciliation Act of 1981(Public Law 97-35). These laws contained, amongother things, provisions designed to encouragehome dialysis, which is less expensive than cen-ter dialysis, to encourage kidney transplantation,which, when successful, is less expensive over thesucceeding years, and to establish composite reim-bursement rates for ESRD services.’

7HCFA data on reimbursements in the End-Stage Renal DiseaseProgram include all Medicare reimbursements that pay for serv-ices used by this population, not only the cost of dialysis and trans-plantation.

‘Provisions to encourage home dialysis in the ESRD ProgramAmendments of 1978 included a waiver of the usual 3-month wait-ing period for entitlement for patients in self dialysis training pro-grams, full coverage for home dialysis supplies, loo-percent reim-bursement for home dialysis equipment, and authorization toestablish target-rate reimbursements to encourage home dialysis.Provisions in the 1978 law to encourage transplantation included

(continued on next page)

Table 7-3.—End-Stage Renal Disease (ESRD) Dialysis Populationby Type and Place of Dialysis, 1980=85°

Dialysis type/place 1980

Total . . . . ...........52,364In-unit hemodialysis ..43,271In-unit peritoneal . . . . . 911Home hemodialysis . . 4,715Home peritoneal . . . . 612CAPD c . . . . . . . . . . . . . . 2,334CCPD d . . . . . . . . . . . . . . –Self training . . . . . . . . . 521

1981 1982 1983 1984 1985

58,924 65,765 71,987 78,483 84,79748,011 52,559 57,029 62,462 67,559

944 885 745 603 5884,481 4,394 4,323 4,125 3,983

646 816 790 259 2314,347 6,523 8,532 9,995 11,236

— — — 859 953495 588 568 481 569

Averageannual Percentpercent changechange 1984-85

10.1 8.09.3 8.2

–8.4 –3.0–3.3 –3.4

–17.7 –13.137.0 14.710.9 14.4

1.8 –48.6%ounts are as of Dec. 31 of each year from ESRD Facility Surveys.%his figure decreased significantly in 1984, partiaiiy due to CCPD patients being counted in this category in previous years.

A CCPD category was added to the ESRD Facility Survey in 1984,CCAPD, Ccmtlnuoljg ambulatory peritoneal dialysis.dCCpD, continuous cyciing peritoneal dialysis. CCPD rate of growth is calculated from 19~.

SOURCE: US. Department of Health and Human Services, Health Care Financing Administration, Bureau of Data Managementand Strategy, Research Repoti: Errd-Sfage Rena/ Disease, 1985 (Washington, DC: U.S. Government Printing Office,in press, 1987),


Table 7-4.—Medicare Reimbursements by Enrollees and Per Capita Reimbursementsfor Persons With End-Stage Renal Disease, 1974-84

ReimbursementReimbursements Enrollment per enrollee

Amount in Percent Number in Percent PercentYear millions change thousands change Amount change

1974 ..., . . . . . . . . . . . . . . . . . $ 228.5 — 16.0 — $14,300 —1975 ......., . . . . . . . . . . . . . 361.1 58.0 22,7 41.9 15,900 11.21976 . . . . . . . . . . . . . . . . . . . . . 512.2 41.8 28.9 27.3 17,720 11.41977 . . . . . . . . . . . . . . . . . . . . . 641.3 25.2 34.8 20.4 18,420 3.91978 . . . . . . . . . . . . . . . . . . . . . 800.0 24.7 43.5 25,0 18,390 –0.21979 . . . . . . . . . . . . . . . . . . . . . 1,010.7 26.3 54.4 25.1 18,579 1.01980 . . . . . . . . . . . . . . . . . . . . . 1,252.2 23.8 61.9 13.8 20,229 8.91981 . . . . . . . . . . . . . . . . . . . . . 1,476,2 17.9 70.4 13.7 20,969 3.71982 . . . . . . . . . . . . . . . . . . . . . 1,660.9 12.5 77.9 10.7 21,321 1.71983 . . . . . . . . . . . . . . . . . . . . . 1,893.6 14.0 86.5 11.0 21,891 2.71984 . . . . . . . . . . . . . . . . . . . . . 1,953.5 3.2 92.8 7.3 21,051 –3.8NOTE: Data are incomplete for most recent years due to continual updating of the payment files.SOURCE: U.S. Department of Health and Human Senfices, Health Care Financing Administration, Bureau of Data Manage-

ment and Strategy, Research Report: %%Stage Rena/Disease, 1985 (VVashin@on, DC: U.S. Government PrintingOffice, in press,1987)

Even though Medicare’s aggregate and per cap-ita expenditures for ESRD have risen annually,when adjusted for inflation in medical care, theper capita expenditure rates have remained almostconstant. As shown in table 7-4, average Medi-care ESRD expenditures per capita rose from$14,300 in 1974 to $21,051 by 1984; when cor-rected for inflation, however, figures for the twoyears were virtually equivalent (29). Data from1974 to 1979 show that while per patient costsfor the ESRD program rose 30.8 percent, duringthe same period, national per capita health expend-itures rose by 74,9 percent and the cost per dayin community hospitals rose 91.4 percent (24). Theaverage annual rate of growth in per enrolleereimbursement levels was less than 4 percent from1974 to 1984 (40).

Treatment for patients on chronic renal dialy-sis includes the dialysis treatments themselves,

(continued from previous page)

extension of the post-transplant Medicare entitlement from 1 to 3years, clarification of coverage for living-related donor costs, andof the reimbursement principles for cadaveric organ procurement.

The Omnibus Budget Reconciliation Act of 1981 directed the HealthCare Financing Administration to develop reimbursement rates fordialysis treatment based on a composite of facility and home dialy-sis costs in order to provide an incentive for home dialysis. Thenew rates implemented in 1983 were $131 per dialysis treatmentin hospital-based facilities, and $127 per dialysis treatment for free-standing facilities. These rates replaced the $128 previously appli-cable to both types of facilities. The act also had a further provisionwhich made Medicare payment secondary to other insurance cov-erage for the first year following onset of chronic renal failure.

physician services both for the supervision of di-alysis and the treatment of other medical prob-lems, any required hospitalizations, and ancillaryservices such as laboratory tests and medications(34). Reasonable estimates of the average annualcosts of treatment of a patient on chronic dialysisrange from $20,000 to $30,000 (1982 dollars) (34).Dialysis treatments themselves account for about70 percent of this total.

The growth in aggregate Medicare expendituresfor ESRD from 1974 to 1983 is primarily attributa-ble to growth in the number of ESRD benefici-aries. From 1974 to 1981, about 76 percent of thegrowth in ESRD reimbursements was due to anincrease in the number of beneficiaries (8).

Hemodialysis in hospital dialysis centers is themost expensive form of dialysis treatment (34).Differences in the cost of treatment by hemodial-ysis performed in independent centers, by hemo-dialysis performed at home, and by CAPD aresufficiently small that they can be accounted forby variations in methods used in available costestimates and by case-mix differences (34).

Medicare approval of CAPD and the use of cy-closporin as an immunosuppressive agent fortransplant patients may have a significant impacton the total costs of Medicare’s ESRD programin the years ahead, Also, Medicare’s Part A pro-spective payment system may shift some costs byencouraging transplantation and outpatient di-alysis.


OUTCOMES

Both the clinical and psychosocial outcomes ofESRD treatment are influenced by the cause ofthe kidney failure, comorbidity, type of treatment,and the willingness and ability of the patient tocooperate with the rigorous treatment regimenthat dialysis entails. Specific information about theoutcomes of dialysis in the elderly population islimited.

Clinical Outcomes

Survival

Survival rates among chronic dialysis patientsappear to be related to a number of factors: ageat the time of starting treatment, cause of renaldisease, and presence of preexisting disease at thetime of starting dialysis (l).

In general, survivalrates are lower amongelderly patients receiving chronic dialysis thanamong younger patients (2)33,49). In 1984, the 1-year survival rate for patients of all ages in Medi-care’s ESRD program was 84.8 percent. For U.S.dialysis patients between the ages of 65 and 74,the l-year survival rate was 77.4 percent; for pa-tients age 75 and over, it was 68.9 percent (table7-5), For ESRD patients over age 65 treated with

OF DIALYSIS

dialysis or transplant at the Northwest Kidney Cen-ter in Seattle, 5-year survival is 25 percent (l).’

The probability of survival while on ESRD treat-ment is closely associated with the primary causeof kidney failure. Patients with kidney failurecaused by diabetic nephropathy 10 pr imaryhypertensive disease have worse survival than pa-tients with other disorders (1). For dialysis patientsin Medicare’s ESRD program whose primary causefor kidney failure was diabetes mellitus, the 1-year survival rate was 74.6 percent in 1984; whenhypertension was the primary cause of renal fail-ure, the survival rate was 82.7 percent (see table7-5).

9The fact that survival rates for elderly dialysis patients are lowerthan those achieved in younger dialysis patients should not be usedto argue against offering dialysis to elderly people. Older peoplein general are expected to die sooner than younger people. Infact,mortality data show that while older people on dialysis for ESRDhave double the average projected 5-year mortality rate for theirage group (7o percent compared with 32 percent), young peopleon dialysis for ESRD ha~’e 100 times the a~’erage projected 5-yearmortality rate for their age group (25 percent compared \iith .25percent) (15,21).

‘(’Diabetic nephropathy is one of the most serious complicationsof diabetes mellitus, a multisystem disease that ad~’ersely affectsthe cardiovascular system with consequent complications of the heartand the blood vessels of the brain, the eLyes, and the kidne~rs.

Table 7-5.— Medicare ESRD Dialysis Patient Survival by Age and Cause of Renal Failure, 1980-84a

1980 1981 1982 1983 1984Survival Survival Survival Survival Survival

rate rate rate rateCharacteristic

rate(percent) Number (percent) Number (percent) Number (percent) Number (percent) Number

Total. ., ., ., ., ... 86.0 33,206 85.5 38,345 85.7 43,324 85.1 47,708 84.8 51,788Age adjusted total . . . . 86.0 85.9 86.5 86.3 86.3

Age:0 to 14 years. . . . . . . 96.3 286 96,8 334 97.7 379 98.9 394 96.6 41915 to 24 years. 96.0 1,729 96.9 1,878 97.7 1,941 97.1 1,975 97.4 1,82825 to 34 years. . . . .. . . . . . . .. . 95.0 3,776 94.4 4,240 94.7 4,665 95.1 4,878 94.9 4,91935 to 44 years, ., ., . . 91.3 4,823 91.3 5,330 92.2 5,865 92.7 6,343 91.7 6,82045 to 54 years, ., ., ., 89.1 6,863 89.0 7,590 90.0 8,346 88.8 8,910 89.1 9,25555 to 64 years, ... 83.7 8,582 83.4 10,020 83.6 11,496 83.2 12,807 83.6 14,03765 to 74 years. ... ., ., 77,0 5,769 76.6 7,040 77.0 8,169 76,8 9,383 77.4 10,79575+ years ., . . ., 67.0 1,378 68.1 1,913 68.1 2,463 69.6 3,018 68.9 3,715

Cause of renal failure:Diabetes ... ., . . 76.4 1,800 73.9 2,248 76.6 2,880 73.4 4,149 74.6 5,616Glomerulonephritis ., 90,5 5,228 89.8 5,893 89.9 6,458 89.2 7,646 87.6 9,379H y p e r t e n s i o n . , 85.2 3,765 84,2 4,541 84.0 5,388 83.4 6,972 82.7 9,074O t h e r / u n k n o w n . , 85.8 22,413 85,7 25,663 86.0 28,598 86.2 28,941 86.6 27,719

al”~lu@S OnIy persons who have surwved for at least one year prior tO January 1 of reference year

SOURCE U S Department of Health and Human Serwces, Health Care Flnanclng Admmlstratlon Bureau of Data Management and Strafegy, Research Report End-Stage Rena/ Dsease, 1985 (WashingtonDC U S Government Prmtmg Off Ice m press 1987)

260 ● Life-Sustaining Technologies and th Elderly

In 1985, the most common primary renal diag-nosis for elderly dialysis patients who died washypertension with heart and renal disease (in 35.7percent of patients who died at ages 65 to 74 andin 35.7 percent who died at age 75 and over) (46).Diabetes mellitus with other complications wasthe second most common kidney diagnosis ofESRD patients dying between ages 65 to 74. Glo-merulonephritis was the second most frequentdiagnosis for those dying at age 75 and over.

The presence of preexisting disease is anotherfactor that affects survival. Severe hypertension,cerebrovascular disease, cancer, and coronary ar-tery disease have an adverse affect on survivalrates (l).

In 1985, the leading cause of death among Medi-care ESRD patients age 65 to 74 and age 75 andover was listed as “cardiac,” accounting for 25 and27 percent of deaths in the two age groups re-spectively (46). Myocardial infarction was the nextmost common cause of death for patients age 65to 74, accounting for almost 15 percent of deaths.In the 75 and over age group, withdrawal fromdialysis was the second most common cause ofdeath, followed closely by myocardial infarction,with each accounting for about 12 percent of thedeaths in that age group (46).

Complications and Morbidity

Patients receiving dialysis for chronic renal fail-ure can experience problems ranging from life-threatening cardiovascular and cerebrovasculardiseases to debilitating diseases of the bones orcentral nervous system, discomforts associatedwith local infections, and the need to replacecatheters. These conditions can be caused by in-fections, metabolic changes, or mechanical prob-lems with the dialysis equipment. Since elderlypatients are more likely than younger patients tosuffer from multiple health problems, they facean increased risk of developing complications.

Some problems are associated with particularforms of dialysis or dialysis settings. Problems asso-ciated with peritoneal dialysis, for example, in-clude mechanical problems such as perforationof the bowel (1). Peritoneal dialysis is also associ-ated with a high risk of peritonitis (i.e., inflamma-tion of the peritoneum). The latest U.S. data on

CAPD show an infection rate of slightly more thanone episode per year of treatment (35). If detectedand treated early, peritonitis often can be treatedat home and rarely causes death. If peritonitisrecurs, however, it can eventually force the pa-tient to change to hemodialysis.

Problems associated with hemodialysis includecomplications related to the vascular access site.These include prolapse or obstruction of the cath-eter or shunt and thrombosis of the arteriovenousfistula. Replacement or transfer of the fistula toanother site may be required, and eventual deple-tion of convenient anatomical sites may necessi-tate changing to another mode of treatment. Ac-cess problems are especially likely in older patientswith arteriosclerotic vessels and in diabetics (34).In dialysis centers, outbreaks of viral hepatitis area serious threat to both patients and staff. Useof the recently developed hepatitis-B vaccine isbeginning to affect the rate of hepatitis B infec-tion, but other forms of hepatitis still occur (l).The development of cardiovascular morbidity in-cluding myocardial infarctions, cerebrovascularaccidents, and advanced peripheral vascular dis-ease may result from preexisting disease, but thepace of these disorders may be accelerated byhemodialysis (34).

Chronic renal failure is almost always associ-ated with anemia, and this is a major factor ina lack of well-being felt by many dialysis patients(1). Inmost patients, anemia is due to reduced pro-duction of erythropoietin by the kidney causinga reduction in red blood cell production (10).Erythropoietin can now be made with recombi-nant DNA techniques, and clinical trials with syn-thetic erythropoietin have reduced patients’ ane-mia. (See app. C, “Future Developments inLife-Sustaining Technologies.) Patients who havenormal iron stores when they begin dialysis typi-cally develop iron deficiency within 6 months to2 years (I). Once this occurs, it may be treatedby oral iron supplements or other methods.

Other conditions associated with dialysis includebone diseases, which occur because of derange-ment in the metabolism of calcium and phospho-rus, and peripheral and central nervous systemproblems. A syndrome known as dialysis enceph-alopathy which includes personality changes and


an abnormal electroencephalogram and progressesto death within a few months, has been linkedto the accumulation of aluminum in the blood andtissues (l).

The major problem affecting long-term survivalamong dialysis patients is cardiovascular disease(l). Plasma lipid abnormalities and hypertensioncan contribute to cardiovascular diseases. Para-thyroid gland disorders and sexual dysfunctionalso can occur.

Various measures can be taken to prevent andreduce the complications and morbidity associ-ated with dialysis. Among these measures are con-trolling hypertension, screening and vaccinatingfor hepatitis, rigorously controlling diet and fluidintake, and meticulously caring for the shunt orcatheter site.

Elderly patients as a group tend to have morechronic diseases than younger patients, and thesecan affect the outcome of dialysis. Diabetes melli-tus, for example, is not only a cause of kidney dis-ease, but may be accompanied by many compli-cations other than those related to the kidney.Degenerative joint disease poses difficulties in mo-bility, which can interfere with a patient’s com-muting to the dialysis center or his ability to man-age self dialysis. Varying degrees of cognitiveimpairment, from mild changes related to cere-bral arteriosclerosis to major problems caused byAlzheimer’s disease, can interfere with a patient’sability to cooperate with the necessary therapeu-tic regimen including diet, control of fluid intake,as well as the dialysis. When lethal diseases suchas metastatic cancer are present in tandem withESRD, they raise difficult ethical questions aboutthe value of continued dialysis.

Psychosocial Outcomes

Maintenance dialysis introduces major difficul-ties into the lives of patients with ESRD. The com-mitment to time-consuming, regular treatmentsdemands that patients order their lives arounda rigid schedule. Dietary and fluid restrictionsmust be carefully followed and travel must becarefully planned. In addition to the more seri-ous complications associated with dialysis, wideswings in blood pressure, weakness, and nauseaare common discomforts.

ESRD patients on dialysis must adjust to the ideaof continued treatment for the remainder of theirlives and the ever-present risk of complicationsrelated both to their renal failure and to dialysisitself. For those patients who are dialyzed in anytype of center, there is the additional problem ofcommuting to and from the center. Transporta-tion may pose a great burden for some elderlypersons.

Some of the chronic stresses associated withESRD include dependency on medical machineryand personnel, the constant threat of death andof reduced life expectancy, and decreased physi-cal strength and stamina. Some researchers havereported feelings of helplessness and depressionamong some dialysis and transplant patients (7).A variety of losses frequently accompany ESRDtreatment and can add to the emotional strain.These include the loss of participation in valuedactivities such as work, family and householdresponsibilities, and leisure activities. These in-trusions threaten the individual’s security and en-joyment of life and may contribute to a sense ofloss of control and reduced self-esteem.

Adjusting to a technology dependent lifestylecan be very difficult. Information about the psy-chosocial effects of dialysis, especially for elderlypatients, is limited, but some evidence suggeststhat elderly patients tolerate dialysis as well as,or better than, many younger dialysis patients(16,49).

A national survey completed in 1985 collecteddata on, among other things, how dialysis and kid-ney transplant patients perceived the quality oftheir lives (12). The data represented a balanceof geographic locations, type of facility, owner-ship, size, academic affiliation, availability of ahome training program, number of patients bytype (home, in-center, CAPD/CCPD, transplant),and service area. Although the data are not rep-resentative of the entire population of dialysis andtransplant patients in the United States, the in-formation provides insights not available fromother sources.

Special analyses done for OTA provide some age-group comparisons (11). Of the 859 patients re-sponding to the survey, about 13 percent were


age 65 or older. More than half of these elderlypatients were between the ages of 65 and 69; halfas many were patients age 70 to 74; and the restwere age 75 or older, Elderly patients (age 65 andover) represented approximately 21 percent ofin-center hemodialysis patients, 10 percent ofhome hemodialysis patients, and 15 percent ofCAPD patients. None of these elderly patients hadreceived a transplant.

In comparison with younger patients, ESRD pa-tients age 65 or over had a higher well-being in-dex, more positive feelings, less negative feelings,and a feeling that their life was easier (11). Theyhad greater satisfaction with life in general and,in particular, with their marriages, family life, sav-ings and investments, and standard of living. Onthe other hand, elderly respondents assessed theirown health as poorer than that of others theirage. They reported greater functional impairment,markedly less ability to work, and a much lowercurrent employment rate than younger patients.Respondents under and over age 65 revealed gen-erally small differences in the “total sickness im-pact profile.” Elderly respondents reported areasonable degree of ability to perform normalactivities. A detailed analysis of overall functionalstatus, using the Karnofsky Index (18), showedthat almost half (47 percent) of the elderly patientsfell in the top three categories: “normal” (2.7 per-cent), “normal activity” (24.3 percent), and “nor-mal activity with effort” (23.4 percent).

Two smaller studies also provide some infor-mation on patients’ satisfaction with their liveson dialysis (26)31). One study focused on ESRDpatients as a whole and the other compared pa-tients between the ages of 55 and 65 with patientswho were 65 or older. In both studies, the vast

majority of respondents said their lives wereworth living, dialysis was worthwhile, and the fu-ture would be better than the present or the past.Ten percent of respondents age 55 to 65 and 20percent of those over age 65 reported that theyhad considered withdrawing from dialysis treat-ment. Also, respondents’ self-assessments of theiroverall health, the number of hospital admissions,and effectiveness of treatment (as measured byblood chemistries) were very similar for these twoage groups.

Another measure of the psychosocial impactsof dialysis is the extent to which patients decideto discontinue treatment. National data indicatethat in 1985, 8.5 percent of patients age 65 to 74and 12 percent of patients over age 75 died asa result of “withdrawal from dialysis” (46). With-drawal from treatment was the third most com-mon cause of death among elderly dialysis pa-tients.

A retrospective study of 1)766 patients in thedialysis program of the Regional Kidney DiseaseCenter in Minnesota found that in 155 cases, dial-ysis was stopped before a biologic cause of deathsupervened (27). In one study that asked ques-tions about the quality of life, 10 percent of re-spondents age 55 to 65 and 20 percent of thoseover age 65 reported that they had consideredwithdrawing from dialysis treatment (31). Whilesuicide among dialysis patients is thought to behigh, statistics on actual or contemplated ‘(with-drawal” cannot be equated with suicide. Some ofthese cases involve patients whose will to live maybe great, but for whom further treatment wouldbe futile. Others are no longer mentally capableand the decision to withdraw dialysis is made bya surrogate.

MAKING DECISIONS ABOUT DIALYSIS

Decisions about starting and stopping dialysisexemplify many of the dilemmas that attend de-cisions about the use of life-sustaining technol-ogies for elderly people. Among the criteria con-sidered in these decisions are those that pertainto the patient and those that relate to the avail-ability of resources. These two types of criteriaare sometimes interdependent. When resources

are scarce, it may be that only those patients forwhom significant medical benefit is most certainwill receive treatment. In times of greater abun-dance, the pool of treatment recipients may ex-pand to include patients for whom the chance ofsignificant improvement is smaller. Sometimes infact, the pool may expand to include patients forwhom treatment offers no real hope of benefit.


For over a decade after it was technically possi-ble to provide chronic dialysis and/or kidney trans-plantation for ESRD patients, the scarcity of re-sources and high cost of the treatment placed itout of reach for most Americans. Patient selec-tion committees were burdened with weighty de-cisions about who should live. The criteria theyused to select patients for treatment included, inaddition to medical and psychological criteria, thecriterion of social worth. Discussions might fo-cus on factors such as the social value of the pa-tient to the community, the family responsibili-ties of the patient, and the patient’s employability.In 1972, however, Congress acted to include pay-ment for ESRD treatment under Medicare, andthese agonizing deliberations over patient selec-tion were ended,

Policymakers in the United Kingdom have takena dramatically different approach to the alloca-tion of ESRD treatment resources (see box 7-A).In the United Kingdom, “the fear of treating toomany inspires greater passion than the fear oftreating too few” (14).

In both the United States and the United King-dom, how ESRD patients are chosen for treatmentand which treatments they receive are determinedat least as much by social priorities as by medicalappropriateness. The difference in the two coun-tries, representing two extremes of the range ofpatient enrollment, are accounted for at leastpartly by their difference in ability and willing-ness to make or avoid “tragic choices. ” As longas funding is available for ESRD treatment through

Box 7-A—Treatment for ESRD in the United Kingdom

264 • Life-Sustaining Technologies and the Elderly

Medicare’s ESRD program, at least some tragicchoices can be avoided.

Decisions About Initiating Dialysis

With payment for ESRD treatment widely avail-able through Medicare’s ESRD program, decisionsabout initiating dialysis in the United States canfocus on considerations pertaining to the individ-ual patient. one potential consideration is whetherdialysis will provide medical benefit to the patient.Determining the likelihood of medical benefit fromdialysis involves assessing a patient’s medical sta-tus and prognosis. This involves the assessmentof systems involved in the patient’s renal disease,as well as any concomitant medical problems.Another potential consideration in decisions aboutinitiating dialysis is the patient’s ability and will-ingness to cope with strict treatment regimens.In some cases, the presence of a condition suchas cancer may lead to a decision not to initiatedialysis. The following case describes an elderlyman who was unwilling to undertake chronic di-alysis treatment:

Decisions About Stopping Dialysis

In some cases, a point may be reached wheredialysis appears to be of no further medical ben-efit, where a patient does not wish to continue,or when a surrogate decision is needed. This pointmay come in a matter of weeks or after manyyears of dialysis treatment.

Decisions to discontinue dialysis are often moredifficult than decisions to start dialysis. The fol-lowing case illustrates some of the decisionmak-ing dilemmas that can arise:

Strong Memorial hospital, the tertiary care cen-ter for the Rochester, New York area, deals withdecisionmaking dilemmas for some dialysis pa-tients by offering patients a trial treatment period


at the end of which the decision to withdraw di-alysis may be considered (13). A trial treatmentperiod allows a patient (and family) an opportu-nity to ‘(try out” dialysis without making an irre-versible decision. It also gives physicians time toestablish a more precise diagnosis, adjust ther-apy to an optimal level, and better assessprognosis.


diabetes. In all age groups except the oldest, dial-ysis was stopped three to five times more oftenamong diabetic patients. Among nondiabetic pa-tients, degenerative diseases such as heart andvascular disease, cancer, and chronic pulmonarydisease were significantly more common in pa-tients from whom dialysis was withdrawn thanin patients who remained on dialysis.

The site of residence could be ascertained for98 of the 155 patients. At the time a decision todiscontinue dialysis therapy was made, 81 per-cent of these patients lived at home. At the timeof death, however, most of the patients who dis-continued dialysis were in hospitals. A small per-centage died at home (13 percent) or in hospices(4 percent).

Decisionmaking Procedures

Initially, ESRD therapy is considered by a pa-tient’s physician, either a family physician whorefers the patient to a nephrologist or a nephrol-ogist who has followed the patient with renal dis-ease for a long time and recognizes that the dis-ease has reached the stage where dialysis and/orrenal transplantation should be considered. Insome centers, especially the larger ones, a reviewcommittee meets regularly to consider the treat-ment to be recommended for each new ESRDpatient–the different types of dialysis, a kidneytransplant, as well as a recommendation not totreat at ail. Such committees usually include rep-resentatives from among the following fields:nephrology, transplantation, urology, nursing, so-cial work, clergy, law, hospital administration, nu-trition, and the dialysis center staff. Often, thepatient and/or patient’s family are asked to attendso they can understand and participate in the deci-sionmaking process and ask questions of the healthteam.

There is almost nothing in print about the cri-teria dialysis centers use to select patients for di-alysis. In January 1984, the Section on Renal Dis-ease, Department of Internal Medicine, Universityof Arizona Health Sciences Center, prepared awritten policy in preparation for a site visit bythe Joint Commission on Accreditation of Hospi-tals. This policy, outlined below, is representativeof the approach described to OTA by many nephrol-

ogists responsible for dialysis patients. Chronicdialysis therapy is provided to every patient,regardless of age, who:

1. grants fully informed consent;2. has chronic, irreversible ESRD;3. has a reasonable expectation of a quality of

life acceptable to himself or herself; and4. desires and can cooperate with such therapy

(48).

One study of the criteria used by physicians toselect patients for ESRD treatment at 373 dialysiscenters and 80 transplantation hospitals (20) ratedpotential patient selection criteria along a 5-pointscale to indicate their importance in decisionmak-ing. Virtually all respondents considered the fol-lowing criteria important: prognosis, psychologi-cal stability, and likelihood of medical benefit. Avery large majority (nearly 90 percent) of respond-ents said they would consider the patient’s will-ingness to participate in treatment and/or considerthe patient’s age indecisions about treatment. Only10 percent of responding dialysis facilities saidthey currently excluded patients because of ad-vanced age, but 85 percent of dialysis centers re-ported that “under conditions of significant scar-city,” they would do so.

There is no uniform mechanism for making de-cisions to withdraw dialysis. Although most phy-sicians consider it their responsibility to make rec-ommendations about appropriate medical care forpatients, the ultimate decision about discontinu-ing treatment usually rests with the patient or pa-tient’s family (27). The case of 78-year-old EarleSpring highlights the legal, ethical, and medicalissues that can surround decisions about the ter-mination of dialysis for patients who are no longerdecisionally capable (see box 7-B).

Ethical Issues

According to some people, because the ESRDprogram covers treatment costs for virtually allESRD patients regardless of age, diagnosis, or anyother factor, there is a strong financial incentiveto provide treatment for all patients who reachESRD, and to continue that treatment as long asit is able to sustain life (25). In some cases, how-ever, the initiation or continuation of dialysis (or


other life-prolonging treatment) may be a burdento the patient.

Any analysis of ethical issues surrounding de-cisions about initiating and terminating dialysistreatment must recognize that Western cultureand the United States place great weight on the

Box 7-B.-The

importance of the individual and the right of self -determination or autonomy. When possible, thepatient must be allowed to decide if a commit-ment to long-term dialysis is worth the trade-off,As discussed throughout this report, medical staffand patients often will differ significantly in whatthey perceive about quality of life. Some patientswith ESRD are incapable of making their own de-

Earle Spring Case

dialysis treatments would have rested where it had 14 months previously-with the court.SOURCE: JJ. Paria, ~th, _ and the Courta: TIM Travesty and Tragedy of tha EM% Spring CWW,” LhMXW @8~ 49:2~1, 1%W.

63-216 0 - 87 - 7 ; QL 3

268 . Life-Sustaining Technologies and the Elderly

cisions about dialysis treatment, and the decisionshave to be made by a surrogate.

Legal Issues

A 66-year-old widow had been on maintenancedialysis for 8 years. In 1978, she had a stroke thatleft her left side paralyzed. In 1983, she hadanother stroke that left her with a right-sidedparalysis, unable to communicate or to performthe simplest task. Her heart was unstable and sherequired monitors and other resources availableonly in the medical ICU. All medical professionalsinvolved in caring for the patient agreed that thepatient’s outlook for recovery and return to ameaningful existence was hopeless, but three ofher sons were adamant that every possible treat-ment be provided. Without the consent of the le-gal next of kin, no one felt that it was ethicallyor legally right to discontinue treatment. The pa-tient remained hospitalized, mostly in the ICU for

FINDINGS AND

An increasing number of elderly patients withESRD are being treated by dialysis. Almost halfthe new patients starting treatment in the UnitedStates are age 55 or older, and almost half the pa-tients enrolled in Medicare’s ESRD program are55 or older (1). These numbers will probably con-tinue to increase (1). Experience has shown thatelderly patients tolerate dialysis reasonably well,and with resources and payment now availablethrough Medicare’s ESRD program, age is not aprominently used criterion in the selection of pa-tients.

The American experience with dialysis for ESRDpresents two major concerns: 1) the high costsof dialysis borne by the Federal Government, pa-tients, and their families; and 2) ethical problemsaccompanying the decisionmaking process in-volved with starting and stopping dialysistreatment.

Through Medicare, the Federal Governmentbears about 80 percent of the cost of treatmentfor ESRD for about 103,000 patients (44). As notedearlier, the cost of Medicare’s ESRD program isnow well over $2. I billion annually, and aggregateexpenditures have been increasing each year. In-

69 days. She died of overwhelming infection, dia-lyzed until the day before her death (13).

Few legal cases have arisen as a result of ESRDtreatment or decisions. One reason for this maybe that dialysis centers are particularly cautiousnot to deny treatment if the patient and/or familyinsist on receiving dialysis, even though the kid-ney team recommends against it. The Universityof Rochester kidney team has commented that ifthere is a potential for litigation, patients will con-tinue to receive dialysis even if the kidney healthcare team believes treatment should be stopped(13). Similar statements have been made by dialy-sis team leaders across the country. Leroy Shear,Director of the Western Massachusetts KidneyCenter noted, “The way I practice medicine is verymuch determined by what the courts tell me todo” (17)28).

IMPLICATIONS

creases in aggregate expenditures are due largelyto growth in the ESRD population. Despite the factthat Medicare’s ESRD population includes a higherpercentage of older and sicker patients, per cap-ita expenditures (when adjusted for inflation) haveremained fairly constant or even decreased overthe life of the program (25).

In part because there are Medicare funds avail-able to cover treatment, dialysis for ESRD is cur-rently available to Americans of all ages. Althoughelderly people as a group tend to have more com-plications and lower survival rates than youngerpeople, a patient’s age alone is not a good predic-tor of the outcome of dialysis. Other importantconsiderations include the cause of a patient’s re-nal failure and the presence of comorbidities.

Typically, a decision to initiate dialysis involvesa recommendation from the health care providersinvolved in a patient’s care. Increasing emphasisis placed on the importance of patient autonomy,however, and major efforts are made to informpatients and their families about all aspects of theirdisease and treatment. In some cases, patients maydecide that they do not want dialysis treatmenteven if it may prolong their lives.


For some patients, a point may be reachedwhere dialysis is no longer beneficial. When a rec-ommendation is made to discontinue dialysis ther-apy, agreement is sought from the patient or, ifthe patient is incapable of participating, from thepatient’s next of kin. In the absence of clear per-mission from either the patient or surrogate, fearof litigation sometimes keeps kidney care teamsfrom discontinuing dialysis even when it is nolonger medically beneficial.

Many elderly patients with ESRD have been re-stored to productive and meaningful lives through

dialysis treatment. others are able to enjoy a qual-ity of life that they find acceptable. Some elderlypatients, however, choose to discontinue dialysis.

Clearly, the ethical decisions associated with di-alysis and its dilemmas must be approached in-dividually. The solutions to the critical dilemmasassociated with ESRD and dialysis, however, mayhave important implications for other catastrophicillnesses and life-sustaining technologies.

CHAPTER 7 REFERENCES

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chapter 7 dialysis for chronic renal failure

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