Blog entry by Arif Khwaja
There is a great recent post by Ajay Singh, Professor of Nephrology at Harvard on his blog The Kidney Doctor talking about the importance of communication with patients. He cites data showing that only 23% of patients are allowed to finish their opening statements when talking to doctors and astonishingly the average time to interruption is only 18 seconds!!
Yet the cost of poor communication remains high. I was reflecting on this as I did my on-call ward rounds this weekend. As in most nephrology units there were a core of dialysis patients for whom dialysis neither improves the quality of life nor life expectancy. These were mostly elderly patients with significant comorbidity many of whom were diabetic. The history was invariably one of recurrent admissions with infections, access problems and fluid overload. All foreseeable and predictable yet patients still ended up in a cycle of recurrent admissions and functional deterioration. Of course the economic cost is significant - a recent analysis of healthcare costs and mortality over the last 200 years at the Massachusetts General Hospital showed some interesting findings. Mortality has fallen precipitously since around 1970 though healthcare costs have risen exponentially. Interestingly whilst costs have continued to rise in the last 10 years mortality no longer seems to be falling - one could speculate that this is perhaps because doctors are losing the art of recognising dying patients and subjecting them to endless interventions with little benefit.
Few of us (myself included) talk about withdrawing treatment until relatively late in the course of treatment and while we like to all talk about patient choice we perhaps need to discuss conservative therapy more openly and honestly.This has been known for many years as Farrington and colleagues showed in Stevenage, UK that dialysis offered no survival advantage in the elderly with significant co-morbidity. Similarly data from the Royal Free Hospital in London showed that those elderly patients with comorbidity who opted to have dialysis did have a survival advantage... Yet virtually all this "extra-time" was spent in hospital. And we know from a large analysis of nursing home residents in the USA that 58% of patients died and only 13% maintained functional status at 1 year.
The clear message is that for many elderly patients with comorbidity, dialysis neither makes people feel better nor makes them live longer. Of course we have known this for years and as it turns out that nephrologists are actually very good at predicting who does badly on dialysis - but many (including myself) need to start listening more to patients and being much more honest with them about dialysis and recognise that whilst dialysis may be palliative for all patients, for some patients dialysis simply doesn't palliate....
1. Two Hundred Years of Hospital Costs and Mortality — MGH and Four Eras of Value in Medicine Gregg S. Meyer, M.D., Akinluwa A. Demehin, M.P.H., Xiu Liu, M.S., and Duncan Neuhauser, Ph.D. N Engl J Med 2012
2. Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease? Rachel C. Carson*, Maciej Juszczak†, Andrew Davenport†, Aine Burns. CJASN
3. Smith C, Da Silva-Gane M, Chandna S, Warwicker P, Greenwood R, Farrington K: Choosing not to dialyse: Evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract 95: c40– c46, 2003
4. Functional Status of Elderly Adults before and after Initiation of DialysisManjula Kurella Tamura, M.D., M.P.H., Kenneth E. Covinsky, M.D., M.P.H., Glenn M. Chertow, M.D., M.P.H., Kristine Yaffe, M.D., C. Seth Landefeld, M.D., and Charles E. McCulloch, Ph.D. N Engl J Med 2009; 361:1539-1547
5. Utility of the “Surprise” Question to Identify Dialysis Patients with High Mortality Alvin H. Moss* †, Jesse Ganjoo*, Sanjay Sharma*, Julie Gansor*, Sharon Senft*, Barbara Weaner*, Cheryl Dalton*, Karen MacKay*, Beth Pellegrino*, Priya Anantharaman*, Rebecca Schmidt* CJASN September 2008 vol 3 , no 5. 1379-1384