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Dialysis in the Elderly: Has It Lived Up to Expectations? Should Age Be a Factor in Nephrology Referrals? Mark T. Hughes, MD, MA Assistant Professor of Medicine Core Faculty, Berman Institute of Bioethics Johns Hopkins University School of Medicine ACP Maryland February 8, 2008
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Page 1: Dialysis in the Elderly

Dialysis in the Elderly:Has It Lived Up to Expectations?

Should Age Be a Factor in Nephrology Referrals?

Mark T. Hughes, MD, MAAssistant Professor of Medicine

Core Faculty, Berman Institute of Bioethics

Johns Hopkins University School of Medicine

ACP Maryland

February 8, 2008

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Disclosures

• No financial or other conflicts of interest

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Goals

1. Review different approaches in the theory of justice in relation to allocation of scarce resources

2. Discuss age as a factor in rationing decisions at the societal level

3. Present ethical issues encountered at the individual level

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Theories of Justice:Allocation of Resources

• Libertarian: linked to autonomy• Utilitarian: grounded in beneficence and

non-maleficence• Egalitarian: linked to equality (reduction

or amelioration of inequality)

• Communitarian: tied to social/relational aspects of life

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0

10

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5th 50th 95thPercentile

Utiles(Well-being,

Survival, QALYs, etc.)

0

10

20

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5th 50th 95thPercentile

Utiles(Well-being,

Survival, QALYs, etc.)

A B

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Utiles(Well-being,

Survival, QALYs, etc.)

C

0

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Utiles(Well-being,

Survival, QALYs, etc.)

D

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0

10

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50

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Utiles(Well-being,

Survival, QALYs, etc.)

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Utiles(Well-being,

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A B

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C

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Utiles(Well-being,

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D

Utilitarian equivalence

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Utiles(Well-being,

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A B

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C

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Survival, QALYs, etc.)

D

Maximin Approach

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Utiles(Well-being,

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A B

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C

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D

Egalitarian Approach

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A B

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C

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D

Egalitarian ApproachMaximin Approach

Utilitarian Approach

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How to Allocate Resources

• Look for those who can pay

• Look for those who are “deserving”– Individual effort, merit, social contribution

• Look for those who are worst off

• Look for those who will most benefit

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Age as a criterion for allocation

• Libertarian: would be opposed• Utilitarian: may favor young on balance,

but depends on utiles counted and size of segment of population

• Egalitarian: may see age cutoff as inequality, but maybe not if take lifespan view

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Moment of time view

• Two people at same time have equal claim

• Usually resolved by “first come, first served”• If exactly same time, then triage:

– Non-combat: the sickest gets the resource

– Disaster/Combat: the one most likely to benefit (fight another day) gets the resource

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Over the lifetime view

• Norman Daniels: Prudential Life Span Account

• Each age group represents stage in person’s life span.

• As prudent deliberators, people would allocate scarce resources over a lifetime in a way that improved chances of attaining a normal life span

• People would reject pattern that reduced chances of living to a normal life span

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Prudential Life Span Account

• You know you have 5 years to live without the resource (dialysis):– You are age 80 and will live to 85

– You are age 40 and will live to 45

• Most people would choose to shift resources to the treatment of younger person to maximize chances of living to normal life span

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The “fair innings” argument

• Everyone entitled to some “normal” life span• The old have had an opportunity to live more

years; the young deserve a chance to live those additional years

• Those falling short of “normal” life span are “cheated”

• Those exceeding the “normal” life span are living on “borrowed time.”

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Communitarian account

• Daniel Callahan: defined age cut-off• Society should guarantee basic care to all,

including provision of palliative care.• Once individuals reach natural life span, no efforts

to extend their lives; only measures to relieve suffering.

• On this view, the elderly have achieved life’s possibilities and view death as relatively acceptable.

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Modifying the Callahan view(Robert Veatch)

Age75

Points forLife-SustainingTreatment

Age

Points forLife-SustainingTreatment

Callahan Veatch

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Arguments against age as a factor

• Ageism as a prejudice• Stereotyping the elderly• Treating elderly as scapegoats for costs• Creating intergenerational conflict• Unfair to deny elderly new technologies that they

did not have access to (and their taxes helped develop)

• Hard to predict when last year of life is (when a quarter of Medicare budget is spent)

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Individual ethical issues

• Respect for autonomous decisions– Understanding personal values/preferences– Informed consent/shared decision-making

• Beneficence: four levels of the patient’s good– Defining the good for this patient

• Truthtelling: pros/cons of dialysis, prognosis• Dealing with uncertainty• Phronesis: practical judgment

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NKF K/DOQI GUIDELINES:Clinical Practice Guidelines and Clinical Practice

Recommendations2006 Updates

Hemodialysis Adequacy

“…the recommended timing of dialysis therapy initiation is a compromise designed to maximize patient QOL by extending the dialysis-free period while avoiding complications that will decrease the length and quality of dialysis-assisted life.”

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Thank you

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Copyright restrictions may apply.

Murtagh, F. E. M. et al. Nephrol. Dial. Transplant. 2007 22:1955-1962; doi:10.1093/ndt/gfm153

(A) Kaplan–Meier survival curves for those with ischaemic heart disease, comparing the dialysis and conservative groups (log rank statistic 1.46, df 1, P = 0.27).

(B) Kaplan–Meier survival curves for those without ischaemic heart disease, comparing the dialysis and conservative groups (log rank statistic 12.78, df 1, P < 0.0001).

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Copyright restrictions may apply.

Murtagh, F. E. M. et al. Nephrol. Dial. Transplant. 2007 22:1955-1962; doi:10.1093/ndt/gfm153

Kaplan-Meier survival curves for those with high comorbidity (score = 2), comparing dialysis and conservative groups (log rank statistic

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Copyright restrictions may apply.

Murtagh, F. E. M. et al. Nephrol. Dial. Transplant. 2007 22:1955-1962; doi:10.1093/ndt/gfm153

Kaplan-Meier survival curves comparing the dialysis and conservative groups (log rank statistic = 13.63, P

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Well-being (Utiles or QALYs)

Pattern of distribution of the good

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Pattern of distribution of the good

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Pattern of distribution of the good

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Pattern of distribution of the goodLinear (Pattern of distribution of the good)

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Table 1. Physicians Questionnaire Scenarios (Wilson R, et al. AJKD 2001)

The angina scenarioSuppose Mr Jones has a creatinine level of 950 mumol/L and some uremic symptoms. He is 55 years old. He has had two prior myocardial infarctions and it is believed he would not benefit from bypass surgery. He is on optimal medical therapy.For each of the following statements, indicate the likelihood that you would refer this patient to a nephrologist for a consideration for dialysis (circle one number)a. He has angina only with heavy exertion.Definitely not refer 1 Probably not refer 2 Uncertain 3 Probably refer 4 Definitely refer 5b. He has angina after walking a mile.c. He has angina after walking 100 yards.d. He has angina after walking 50 yards.e. He has angina at rest.

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The cancer scenario

Mr. Jones has a creatinine level of 950 mumol/L and some uremic symptoms. He is 55 years old. He does not have heart disease.a) He had Hodgkins disease diagnosed a year ago and is currently in remission (5-year remission rate, 75%-85%).b) He had Duke's stage C carcinoma of the colon resected 1 year ago and is receiving chemotherapy (5-year survival rate, 40%).c) He had multiple myeloma diagnosed 1 year ago and is receiving chemotherapy (1-year survival rate, 26%).d) He has metastatic malignant melanoma and is receiving palliative care. He uses morphine for pain.

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The mental status scenario

Mr. Jones has a creatinine level of 950 mumol/L and some uremic symptoms. He is 55 years old. He does not have heart disease, diabetes, or cancer.a) He is depressed but not suicidal.b) He is depressed and suicidal.c) He has chronic schizophrenia and a tendency to violence if confined.d) He has Alzheimer's disease and will require institutional care within 2-3 months.e) He has a mental age of 8 years. He lives in a group home for the developmentally disabled.

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The social scenario

Mr. Jones has a creatinine level of 950 mumol/L and some uremic symptoms. He is 55 years old. He does not have heart disease, diabetes, or cancer.a) He is employed and lives with his wife, who also works. They have no children.b) He is depressed and suicidal.c) He is unemployed and on welfare. His wife does not work. They have two children.d) He is employed and lives with his wife, who is physically disabled (uses a wheelchair). They have two children.e) He is employed. He lives a promiscuous gay lifestyle. He refuses to be tested for human immunodeficiency virus.

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Survey results regarding ageWilson R, et al. End-stage renal disease: Factors affecting referral decisions by family physicians in Canada, the United States, and Britain. Am J Kid Dis 2001; 38(1):42-48

● 65% American/Canadian physicians refer for dialysis regardless of age

● 49% British physicians would refer for dialysis regardless of age

● Mean age for non-referral: 85 (US/Canada)82 (Britain)

● Non-referral: Women (85 years); men (83years)