Patients who choose not to dialyze

Abstract

Introduction and aims: Some patients with Stage 5 chronic kidney disease (CKD) choose supportive non-dialytic management or conservative care in preference to dialysis. The aims of this study were to estimate the national proportion of incident CKD Stage 5 patients referred to Nephrologists who choose not to dialyse, and investigate their characteristics. Methods: A prospective national multi-centre study of information given to incident CKD Stage 5 patients in Australian renal units, identified between 1st July and 30th September 2009. Patients with CKD who had not been referred to a nephrologist were excluded. Multi-level logistic regression models were used to determine which patient and unit characteristics were associated with receiving information about the option of conservative care and determine which characteristics were associated with commencement of conservative care compared to renal replacement therapy. Results: Sixty-six (90%) of 73 Australian renal units participated in the study. 102 of 721 (14%) of incident CKD Stage 5 patients chose not to dialyse, mean age 79 years (standard deviation 8.7). Nine of 50 (18%) of renal units managing conservative patients had a formal conservative care pathway. In multivariable analysis, age (p<0.001), language (p=0.0396), time known to a nephrologist (p<0.001), and the presence of a support person (p<0.001) were associated with the presentation of information about conservative care options. After adjusting for the patient’s gender, insurance status, size of the renal unit and presence of a formal conservative care pathway, patients over 60 years, OR 3.78(95% CI 2.39-5.00), non-English speakers, OR 2.52(95% CI 1.08-5.90), and those known to a nephrologist for more than 3 months, OR 5.83(95% CI 2.90-11.71), were more likely to receive information about conservative care. In unadjusted analysis the absence of a support person was strongly associated with a lower likelihood of receiving information about conservative care, OR 0.54(95% CI 0.34-0.86) however this effect lessened when adjusted for other factors, OR 0.65 (95% CI 0.39-1.09). In the second multivariable analysis that compared commencement of conservative care to renal replacement therapy, age (p<0.0001), gender (p=0.0169) and earlier CKD stage when treatment options were presented (p=0.027) were associated with commencement of conservative care. Patients older than 60 years, OR 7.84(95% CI 2.78-22.06); females, OR 2.01(95% CI 1.13-3.59); and those receiving information about their treatment options in Stage 3/4 CKD compared to Stage 5, OR 2.41 (95% CI 1.25-4.64), were more likely to decline renal replacement therapy. Conclusions: A considerable proportion (14%), of Australian CKD Stage 5 patients managed by Nephrologists choose conservative care, despite a lack of formal care pathways. Earlier presentation of treatment options including conservative care, to an older CKD population may result in more informed patient decision making, with choices being more strongly aligned to patient preferences. Further research is required in this area as many nephrologists feel unprepared or uncomfortable in discussions with patients about palliative treatment.