NEPHROLOGY - LETTER TO THE EDITOR

Happy, ‘healthy’ and enjoying life on dialysis: an elderlyperspective

Adam D. Jakes • Ahsan Syed • Anoop Amarnath •

Sunil Bhandari

Received: 19 June 2013 / Accepted: 12 September 2013 / Published online: 28 September 2013

� Springer Science+Business Media Dordrecht 2013

Editor,

Over the last two decades, the age of patients requiring

renal replacement therapy (RRT) has increased. These

patients are potentially much frailer, with multiple co-

morbidities and lower life expectancy [1]. It remains

unclear whether they benefit from RRT both in terms of

quality and quantity of life [5]. Objective measurements

like co-morbidity indices help clinicians, patients and

caregivers make informed decisions about continuing or

withdrawing dialysis therapy.

This semi-qualitative questionnaire-based study exam-

ined whether subjective measurements such as perception

of good health also contributed to these decisions. Twenty-

seven patients (17 male) from a satellite dialysis unit were

studied. The KDQOL-36 (Kidney Disease Quality of Life)

questionnaire and a questionnaire regarding possible

treatment withdrawal, end of life care and cardio-pul-

monary resuscitation (CPR) were used. The average

Charlson Co-morbidity Index was 8.76 (range 5–12), and

2-year survival was 46 ± 11 %; however, 85 % of patients

considered their health to be ‘fair’ or ‘good’. Although

dialysis nurses and clinicians felt that only 48 and 56 % of

patients, respectively, would benefit from intervention,

92 % wanted CPR attempted. Thirteen (48 %) patients had

poor mobility but most (85 %) had assistance from carers.

Eight (30 %) patients felt they were a burden on their

family. However, most patients were rarely downhearted or

sad, and the majority had not considered future withdrawal

of dialysis therapy or its implications.

Perception of good health is an important, if not integral,

part of decision-making. In this study, most patients per-

ceived their health to be fair or good, despite a belief by

many that they were a burden on their family. As a clini-

cian, one cannot assume that advanced biological age in

itself is a reason to consider stopping treatment. Dialysis

patients are getting older and one needs to be sensitive

towards their views on both continuing life and future

death. Planning end-of-life care is essential, requiring open

and honest discussion, with regular review of patients’

needs and preferences (including resuscitation wishes).

Adequate infrastructure is required to deliver the necessary

social and community support for patients and their fami-

lies, as indicated in the end of life strategy [2]. Although

cognitive impairment due to old age is a precipitating

factor for withdrawal, other factors include unacceptable

quality of life, depression and chronic failure to thrive [3]

(malaise, weight loss and poor self-care). On the other

hand, factors contributing towards continuation of dialysis

therapy include fear of dying, pain, suffering and percep-

tion of abandonment [3]. Recognised guidelines from both

the UK [2, 4] and USA [5] describe methods of achieving

good quality end-of-life care. Common aspects include

recognition and appropriate timing of discussions, good

communication with patients/carers, eliciting preference of

level of care and place of death, and symptom control.

Given the issues involved it is imperative that the factors

influencing withdrawal of dialysis are better understood.

Although objective measurements of co-morbidities assist

in deciding continuation/withdrawal of dialysis among

elderly patients, subjective measurements like perception

A. D. Jakes

Leeds Teaching Hospitals NHS Trust, Leeds, UK

e-mail: adam.jakes@hyms.ac.uk

A. Syed � A. Amarnath � S. Bhandari (&)

Renal Unit, Hull and East Yorkshire Hospitals NHS Trust and

Hull York Medical School, Anlaby Road, Kingston upon Hull

HU3 2JZ, UK

e-mail: Sunil.bhandari@hey.nhs.uk

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Int Urol Nephrol (2014) 46:1035–1036

DOI 10.1007/s11255-013-0568-y

of good health should be taken into consideration. A larger

study is required to validate our findings. Perhaps sub-

jective scores of health perception would be a useful tool to

aid decision-making.

Conflict of interest All authors declare that they have (1) no sup-

port from any company for the submitted work, (2) no relationships

with any company that might have an interest in the submitted work

in the previous 3 years and (3) no non-financial interests that may be

relevant to the submitted work. They also declare that their spouses,

partners or children have no financial relationships that may be rel-

evant to the submitted work.

References

1. Krishnan M, Lok CE, Jassal SV (2002) Epidemiology and

demographic aspects of treated end-stage renal disease in the

elderly. Semin Dial 15:79–83

2. End of Life Care in Advanced Kidney Disease (2009) A

framework for implementation. National end of life care

Programme/NHS kidney care

3. White Y, Fitzpatrick G (2006) Dialysis: prolonging life or

prolonging dying? Ethical, legal and professional considerations

for end of life decision making. EDTNA ERCA J 32(2):99–103

4. Farrington K, Graham W (2009) Planning, initiating and with-

drawal of renal replacement therapy. UK Renal Association

5. Moss AH (2010) Revised dialysis clinical practice guideline

promotes more informed decision-making. Clin J Am Soc Nephrol

5:2380–2383

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