Bjorg Thorsteinsdottir

Ageism vs the technical imperative, applying the GRADE framework to the evidence on hemodialysis in very elderly patients

Purpose Treatment intensity for elderly patients with end-stage renal disease has escalated beyond population growth. Ageism seems to have given way to a powerful imperative to treat patients irrespective of age, prognosis, or functional status. Hemodialysis (HD) is a prime example of this trend. Recent articles have questioned this practice. This paper aims to identify existing pre-synthesized evidence on HD in the very elderly and frame it from the perspective of a clinician who needs to involve their patient in a treatment decision. Patients and methods A comprehensive search of several databases from January 2002 to August 2012 was conducted for systematic reviews of clinical and economic outcomes of HD in the elderly. We also contacted experts to identify additional references. We applied the rigorous framework of decisional factors of the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) to evaluate the quality of evidence and strength of recommendations. Results We found nine eligible systematic reviews. The quality of the evidence to support the current recommendation of HD initiation for most very elderly patients is very low. There is significant uncertainty in the balance of benefits and risks, patient preference, and whether default HD in this patient population is a wise use of resources. Conclusion Following the GRADE framework, recommendation for HD in this population would be weak. This means it should not be considered standard of care and should only be started based on the well-informed patient’s values and preferences. More studies are needed to delineate the true treatment effect and to guide future practice and policy.

Page Kidney: Etiology, Renal Function Outcomes and Risk for Future Hypertension

J Clin Hypertens (Greenwich). 2012;14:216–221. ©2012 Wiley Periodicals, Inc.

Health Care Outcomes and Advance Care Planning in Older Adults Who Receive Home-Based Palliative Care: A Pilot Cohort Study

BACKGROUND Approximately 20% of seniors live with five or more chronic medical illnesses. Terminal stages of their lives are often characterized by repeated burdensome hospitalizations and advance care directives are insufficiently addressed. This study reports on the preliminary results of a Palliative Care Homebound Program (PCHP) at the Mayo Clinic in Rochester, Minnesota to service these vulnerable populations. OBJECTIVE The study objective was to evaluate inpatient hospital utilization and the adequacy of advance care planning in patients who receive home-based palliative care. METHODS This is a retrospective pilot cohort study of patients enrolled in the PCHP between September 2012 and March 2013. Two control patients were matched to each intervention patient by propensity scoring methods that factor in risk and prognosis. Primary outcomes were six-month hospital utilization including ER visits. Secondary outcomes evaluated advance care directive completion and overall mortality. RESULTS Patients enrolled in the PCHP group (n = 54) were matched to 108 controls with an average age of 87 years. Ninety-two percent of controls and 33% of PCHP patients were admitted to the hospital at least once. The average number of hospital admissions was 1.36 per patient for controls versus 0.35 in the PCHP (p < 0.001). Total hospital days were reduced by 5.13 days. There was no difference between rates of ER visits. Advanced care directive were completed more often in the intervention group (98%) as compared to controls (31%), with p < 0.001. Goals of care discussions were held at least once for all patients in the PCHP group, compared to 41% in the controls.

Dialysis in the Frail Elderly — A Current Ethical Problem, an Impending Ethical Crisis

ABSTRACTThe current practice of hemodialysis for the frail elderly frequently ignores core bioethical principles. Lack of transparency and shared decision making coupled with financial incentives to treat have resulted in problems of overtreatment near the end of life. Imminent changes in reimbursement for hemodialysis will reverse the financial incentives to favor not treating high-risk patients. In this article, we describe what is empirically known about the approach to hemodialysis today, and how it violates four core ethical principles. We then discuss how the new financial system turns physician and organizational incentives upside down in ways that may exacerbate the ethical dilemmas, but in the opposite direction.

The Ethics of Chronic Dialysis for the Older Patient: Time to Reevaluate the Norms

Recent research highlights the potential burdens of hemodialysis for older patients with significant comorbidities, for whom there is clinical equipoise regarding the net benefits. With the advent of accountable care and bundled payment, previous incentives to offer hemodialysis to as many patients as possible are being replaced with a disincentive to dialyze high-risk patients. While this may offset the harm of overtreatment for some elderly patients, some voice concerns that the pendulum will swing too far back, with a return to ageist rationing of hemodialysis. Nephrologists should ensure that the patients rights to be informed about the potential benefits and burdens of hemodialysis are respected, particularly because age, functional status, nutritional status, and comorbidities affect the net balance between benefits and burdens. Nephrologists are also called on to help patients make a decision, for which the patients goals of care guide determination of potential benefit from hemodialysis. This article addresses concerns about present overtreatment and future risk of undertreatment of older adults with ESRD. It also discusses ways in which providers can ethically approach the question of initiation of hemodialysis in the elderly patient by including patient-specific estimates of prognosis, shared decision-making, and the use of specialist palliative care clinicians or ethics consultants for complex cases.

Adverse outcomes of renovascular hypertension during pregnancy

Background A 26-year-old primigravida, with no history of hypertension, presented at 20 weeks of gestation with severe pre-eclampsia. A pelvic ultrasound revealed intrauterine fetal death, probably caused by placental abruption. The pregnancy was terminated by induction with oxytocin, followed by a vaginal breech delivery. The patient remained hypertensive for 8 weeks after delivery.Investigations Physical examination, laboratory investigation, renal angiogram and renal-vein renin sampling.Diagnosis An atrophic right kidney secondary to an occluded right renal artery, probably caused by dissected fibromuscular dysplasia; a contralateral high-grade stenosis secondary to fibromuscular dysplasia.Management Right nephrectomy and angioplasty of the left renal artery.

The ABCs of Asthma Control

The new asthma guidelines have introduced impairment and risk assessments into the management of asthma. Impairment assessment is based on symptom frequency and pulmonary function, whereas risk assessment is based on exacerbation frequency and severity. These 2 measures determine the initial severity of asthma in the untreated patient as well as the degree of control in asthma once treatment has been initiated. The focus on asthma control is important because the attainment of control correlates with a better quality of life and reduction in health care use. We describe 4 easy steps to achieving asthma control in the ambulatory practice setting: (1) a standardized assessment of asthma symptoms using a 5-question assessment tool called the Asthma Control Test, (2) a simple mnemonic that provides a systematic review of the comorbidities and clinical variables that contribute to uncontrolled asthma, (3) directed patient education, and (4) a schedule for ongoing care. Most if not all patients can achieve good control of their asthma with optimal care through an active partnership with their health care professionals.

Abdominal wall cellulitis in the morbidly obese

Currently, almost two-thirds of the US population is either overweight or obese. In addition to non-infectious complications, obesity predisposes to infections, including lower extremity cellulitis. Although cases of abdominal wall cellulitis in the morbidly obese occur, to date there has been no formal address of this syndrome in the literature. We therefore reviewed our clinical experience of abdominal wall cellulitis complicating morbid obesity. A retrospective database search was performed to identify patients with both cellulitis and morbid obesity who were seen at the Mayo Clinic between January 1998 and August 2003. Clinical and microbiologic data were collected for these patients. Of the 260 cases of cellulitis identified, 24 (9.2%) had morbid obesity and abdominal wall cellulitis. The mean age of the 24 patients was 47 (range 22–70) y and over two-thirds of them were females. Their mean body mass index (BMI) was 62.3 (range 39.6–108.6). 17 (70.8%) had a remote history of abdominal surgery. 16 patients required 23 hospitalizations. Five patients developed cellulitis complications and 7 (29.1%) patients had recurrent bouts of cellulitis during the study period. Abdominal wall cellulitis is a unique infectious complication in patients with morbid obesity. Further study is needed to better define the pathogenesis of this illness to develop strategies in treatment and prevention.

The impact of telemonitoring upon hospice referral in the community: a randomized controlled trial

Background Using telemedicine for older adults with multiple comorbid conditions is a potential area for growth in health care. Given this older, ailing population, providers should discuss end-of-life care with patients. Objective To determine the relationship between telemonitoring and hospice enrollment compared to usual care among older adults with chronic health problems. Methods This was a secondary evaluation of a randomized controlled trial. The trial was performed at an academic medical center. Patients who were over the age of 60 and had a high risk of hospitalization and emergency department visits were recruited to the study. The primary outcome was hospice enrollment, and the secondary outcome was the mean number of days in hospice. The data were analyzed using Chi-squared tests and time-to-event analysis. Results The average age of the cohort was 80.3 years. Nine patients (9.6%) in the telemonitoring group were enrolled in hospice care, whereas four patients (4.0%) in the usual care group were enrolled (P = 0.12). The mean number of days in hospice was 57.9 (SD ± 99.2) for the telemonitoring group, and 119.3 (SD ± 123.8) for the usual care group (P = 0.36). There was no significant difference regarding time to hospice referral. Conclusion In this pilot analysis, there were no differences noted between groups in the number of patients that entered into hospice or the amount of time they stayed in hospice care. This was a small trial, and the power to detect a difference was 36%. It was encouraging that twice the number of patients enrolled in hospice care in the telemonitoring group compared to usual care despite the insignificant finding. Further research may determine the effect of telemonitoring upon hospice referral.

Ethical challenges with hemodialysis patients who lack decision-making capacity: behavioral issues, surrogate decision-makers, and end-of-life situations

Hemodialysis (HD) is routinely offered to patients with end-stage renal disease in the United States who are ineligible for other renal replacement modalities. The frequency of HD among the US population is greater than all other countries, except Taiwan and Japan. In US, patients are often dialyzed irrespective of age, comorbidities, prognosis, or decision-making capacity. Determination of when patients can no longer dialyze is variable and can be dialysis-center specific. Determinants may be related to progressive comorbidities and frailty, mobility or access issues, patient self-determination, or an inability to tolerate the treatment safely for any number of reasons (e.g., hypotension, behavioral issues). Behavioral issues may impact the safety of not only patients themselves, but also those around them. In this article the authors present the case of an elderly patient on HD with progressive cognitive impairment and combative behavior placing him and others at risk of physical harm. The authors discuss the medical, ethical, legal, and psychosocial challenges to care of such patients who lack decision-making capacity with a focus on variable approaches by regions and culture. This manuscript provides recommendations and highlights resources to assist nephrologists, dialysis personnel, ethics consultants, and palliative medicine teams in managing such patients to resolve conflict.