Ethical Concerns in the Care of Patients with Advanced Kidney Disease: a National Retrospective Study, 2000–2011

Abstract

Background: Understanding ethical concerns that arise in the care of patients with advanced kidney disease may help identify opportunities to support medical decision-making. Objective: To describe the clinical contexts and types of ethical concerns that arise in the care of patients with advanced kidney disease. Design: Retrospective cohort study. Participants: A total of 28,568 Veterans with advanced kidney disease between 2000 and 2009 followed through death or 2011. Exposure: Clinical scenarios that prompted clinicians to consider an ethics consultation as documented in the medical record. Main Measures: Dialysis initiation, dialysis discontinuation, receipt of an intensive procedure during the final month of life, and hospice enrollment. Key Results: Patients had a mean age of 67.1 years, and the majority were male (98.5%) and white (59.0%). Clinicians considered an ethics consultation for 794 patients (2.5%) over a median follow-up period of 2.7 years. Ethical concerns involved code status (37.8%), dialysis (54.5%), other invasive treatments (40.6%), and noninvasive treatments (61.1%) and were related to conflicts between patients, their surrogates, and/or clinicians about treatment preferences (79.3%), who had authority to make healthcare decisions (65.9%), and meeting the care needs of patients versus obligations to others (10.6%). Among the 20,583 patients who died during follow-up, those for whom clinicians had considered an ethics consultation were less likely to have been treated with dialysis (47.6% versus 62.0%, adjusted odds ratio [aOR] 0.63, 95% CI 0.53–0.74), more likely to have discontinued dialysis (32.5% versus 20.9%, aOR 2.07, CI 1.61–2.66), and less likely to have received an intensive procedure in the last month of life (8.9% versus 18.9%, aOR 0.41, CI 0.32–0.54) compared with patients without documentation of clinicians having considered consultation. Conclusions: Clinicians considered an ethics consultation for patients with advanced kidney disease in situations of conflicting preferences regarding dialysis and other intensive treatments, especially when these treatments were not pursued.