Parents Refusing Dialysis for a 3-Month-Old With Renal Failure.

A 3-month-old boy with failure to thrive was referred to a nephrology clinic after a diagnostic workup for failure to thrive revealed a serum urea nitrogen level of 95 mg/dL and creatinine level of 3.6 mg/dL. A renal ultrasound revealed marked bilateral hydronephrosis with little remaining renal cortex in either kidney. A voiding cystourethrogram revealed evidence of posterior urethral valves. The child had no evident comorbidities. Fulguration of the valves was successfully performed but did not lead to improvement in kidney function. The nephrologists recommended the initiation of dialysis with the hope that the child would be able to receive a kidney transplant in the future. After careful consideration, the family stated that they did not want this child to suffer with a lifetime of dialysis and transplant care. They were also concerned about the impact of this child's illness on their other 2 children and their family. They requested that their son be provided with palliative care only. Experts in nephrology, bioethics, and critical care discuss the ethical issues raised by this parental request.

Shared decision making and patient involvement in choosing home therapies.

BACKGROUND: Patient involvement through shared decision making is advocated to support patients deciding on a dialysis treatment suitable to their clinical condition, lifestyle and social circumstances. Evidence to date, however, suggests that shared decision making is far from routine practice. Not all physicians or patients are willing to participate in shared decision making. Equally, modality education does not always meet the needs of patients and their families, resulting in a significant proportion of patients remaining unaware of the existence of home therapies. The selection of home therapies appears to be tightly associated with the quality of the modality education. This paper considers several ways in which patient involvement in their dialysis modality decision can be improved, with particular reference to information provision. Information needs to be balanced, explore the medical as well as the psychosocial aspects of each treatment, be tailored to the needs of the individual patient and be delivered in a timely fashion. CONCLUSION: Optimising modality education will optimise patient's ability to participate in shared decision making, thereby improving uptake of home therapies.