Scientists at the Stanford University School of Medicine claim that older Americans living in nursing homes undergo a considerable decline in their ability to carry out simple daily tasks after starting dialysis. Supposedly, everyday activities include feeding themselves, getting dressed or brushing their teeth.
Dialysis is known to be a method of removing waste products from the blood when the kidneys fail. Also, this dialysis could perhaps be an exhausting therapy for the fragile elderly.
Moreover, patients are noted to be required to travel to and from the nursing home to dialysis centers for their treatments. Usually this may take place thrice a week for about three to four hours per treatment. It was observed that many patients have frequent hospitalizations for disease or treatment related complications.
Americans over the age of 80 are known to be the fastest-growing sector of the dialysis population. However, this increase appears to be unexplained merely by population growth or an increase in diseases which cause kidney failure such as diabetes. Kurella Tamura was of the opinion that this seems to be because physicians are much more willing to provide dialysis therapy to the very elderly.
Lead author of a study, Manjula Kurella Tamura, MD and assistant professor of nephrology said that, “The findings are sobering. One of the rationales for starting dialysis in patients with limited life expectancy due to diseases other than kidney failure is that, even if dialysis doesn’t extend life, it will improve the quality of life by alleviating symptoms of kidney failure or improving the ability of a patient to care for themselves.”
For the purpose of the study, Tamura along with his colleagues from Stanford and the University of California-San Francisco recognized nearly 3,702 nursing home patients from national registries who had started dialysis between June 1998 and October 2000. Also, these patients seem to have at least one measurement of their functional status accessible before they began the treatment.
Functional status is known to be considered as an essential aspect of quality of life and strong predictor of survival. In addition, it appears to have been measured by assessing the degree of dependence in several activities of daily living, such as eating, dressing, using the bathroom and changing positions in bed. Subsequently, they were believed to have compared the patients’ functional status over the year earlier to dialysis to the year following treatment.
They found that 12 months after starting dialysis, nearly 58 percent of the patients seemed to have died. Only 13 percent appear to have maintained the functional level they had before starting dialysis.
“We have tended to overestimate the benefits and ignore or downplay the negative aspects of dialysis when we counsel patients about their treatment options. There’s a huge burden of adverse symptoms and physical disability even among the patients who receive dialysis, and these aspects are sometimes easy to overlook,” explains Kurella Tamura.
After analyzing the findings, Peter Aronson, MD, a professor of nephrology at Yale University who was not involved in the study, said that, “It’s a real eye-opener to see how poorly patients do. The study will be very useful for clinicians in counseling elderly nursing home patients about their care decisions.”
Aronson was of the opinion that increasing the training for nephrologists on end-of-life cares issues. It was estimated that at least one third of these patients experience multiple chronic illnesses, such as heart disease and diabetes, as well as kidney failure. Within the United States, approximately 400,000 patients seem to receive dialysis treatment.
“Many patients have false hopes when they start dialysis. When doctors don’t have realistic expectations about how their patients will do, I think it is very hard for patients to make appropriate decisions about their care,” continues Aronson.
In nursing home patients with multiple chronic illnesses, kidney failure could possibly be a sign of the dying process. Additionally, this may elucidate why functioning continues to decline in spite of starting dialysis.
“In some of these patients, dialysis may be prolonging suffering rather than prolonging life,” adds Kurella Tamura.
She further said that, “My hope is that this information will encourage physicians to have open and honest discussions about the treatment choices for kidney failure and the expected outcomes. There should be an individualized approach that takes into account the patient’s goals of care along with prognostic information. Some patients may choose a palliative treatment approach and others may choose dialysis. Regardless of what treatment they choose, this information can help patients prepare for a decrease in their abilities to function and plan for that.”
The findings revealed that the initial dialysis in treating kidney failure seemed to have failed to assist nursing home patients in maintaining or improving their functional capacity. The study also found that depending on a patient’s other medical problems could possibly be untrue.
In an additional editorial in the journal, two kidney disease experts were observed to have pointed out the importance of effective rehabilitation during dialysis for the frail elderly in reference to the study results. As well as the need to better educate elderly patients and their doctors on the benefits and drawbacks of the treatment.
The authors claimed that many clinicians believe that declining dialysis treatment is a ‘death sentence.’ They further said that the research by Kurella Tamura reveals the need for larger studies that may possibly be crucial in determining the exact benefit from dialysis in frail elders.
The findings of the study have been published in the New England Journal of Medicine.