ABSTRACT
Thoughtful decision-making in a patient with cancer and kidney disease requires a comprehensive discussion of prognosis and therapy options for both conditions framed by the individual's preferences and goals of care. An estimate of overall prognosis is generated that includes the patient's clinical presentation and parameters associated with adverse outcomes, such as age, performance status, frailty, malnutrition, and comorbidities. Empathic communication of this information using a shared decision-making approach can lead to an informed decision that respects patient autonomy and is consistent with the patient's "big-picture" goals and personal values.
Subject(s)
Decision Making , Kidney Diseases/therapy , Neoplasms/therapy , Palliative Care , Patient Care Planning , Patient Participation , Acute Kidney Injury/complications , Acute Kidney Injury/therapy , Communication , Humans , Kidney Diseases/complications , Kidney Failure, Chronic/complications , Kidney Failure, Chronic/therapy , Neoplasms/complications , Physician-Patient Relations , Prognosis , Renal Dialysis , Renal Insufficiency, Chronic/complications , Renal Insufficiency, Chronic/therapyABSTRACT
Because the fastest-growing group of patients undergoing dialysis is older than 75 years, geriatricians will be more involved in decisions regarding the appropriate treatment of end-stage renal disease. A thoughtful approach to shared decision making regarding dialysis or nondialysis medical therapy (NDMT) includes consideration of medical indications, patient preferences, quality of life, and contextual features. Determination of prognosis and expected performance on dialysis based on disease trajectories and assessment of functional age should be shared with patients and families. The Renal Physician Association's guidelines on shared decision making in dialysis offer recommendations to help with dialysis or NDMT decisions.
Subject(s)
Activities of Daily Living , Kidney Failure, Chronic , Palliative Care , Patient Selection , Quality of Life , Aged , Aged, 80 and over , Contraindications , Decision Making , Geriatric Assessment/methods , Guidelines as Topic , Humans , Karnofsky Performance Status , Kidney Failure, Chronic/mortality , Kidney Failure, Chronic/psychology , Kidney Failure, Chronic/therapy , Outcome Assessment, Health Care , Palliative Care/methods , Palliative Care/psychology , Patient Participation , Prognosis , Renal Dialysis , Risk Adjustment , Survival AnalysisABSTRACT
Elderly patients with advanced chronic kidney disease or who are on dialysis should be able to live as fully and comfortably as possible. Geriatric patients are most interested in outcomes that will optimize mental and physical function and limit suffering and pain. Nephrologists must help them answer the question: "How will my kidney problem affect the way I live now and in the future?" This means management must move beyond glomerular filtration rate-related targets and incorporate geriatric principles that focus on assessment of function, comorbidities, geriatric syndromes, and quality of life issues. Therapeutic decisions should be individualized and directed by patient goals of care, which must be explored and documented. Accomplishing this requires inclusion of the patient's family-support system in the shared decision-making process. There is no substitute for spending time listening to and understanding the patient and family agenda, providing timely medical and prognostic updates; discussing realistic scenarios to balance expectations; and planting the seeds of change as the quantity and quality of medical events, geriatric syndromes, and comorbidities accumulate. Synergy of the interdisciplinary renal team with geriatric and palliative medicine specialists provides the expertise to achieve these goals. This falls into the domain of geriatric renal palliative or supportive care (1) and is the subject of this practical review.
