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Kidney Int. 2014 Sep;86(3):475-80. doi: 10.1038/ki.2014.231. Epub 2014 Jul 2.

Ethical challenges with hemodialysis patients who lack decision-making capacity: behavioral issues, surrogate decision-makers, and end-of-life situations.

Author information

1
1] Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA [2] Division of General Internal Medicine, Section of Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
2
1] Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA [2] Division of Nephrology Mayo Clinic, Rochester, Minnesota, USA.
3
1] Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA [2] Division of Primary Care Internal Medicine Mayo Clinic, Rochester, Minnesota, USA [3] Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery and Bioethics Research Program, Mayo Clinic, Rochester, Minnesota, USA.
4
Center for Health Ethics and Law, Section of Nephrology, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, West Virginia, USA.
5
1] Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA [2] Division of General Internal Medicine, Section of Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA [3] Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery and Bioethics Research Program, Mayo Clinic, Rochester, Minnesota, USA.

Abstract

Hemodialysis (HD) is routinely offered to patients with end-stage renal disease in the United States who are ineligible for other renal replacement modalities. The frequency of HD among the US population is greater than all other countries, except Taiwan and Japan. In US, patients are often dialyzed irrespective of age, comorbidities, prognosis, or decision-making capacity. Determination of when patients can no longer dialyze is variable and can be dialysis-center specific. Determinants may be related to progressive comorbidities and frailty, mobility or access issues, patient self-determination, or an inability to tolerate the treatment safely for any number of reasons (e.g., hypotension, behavioral issues). Behavioral issues may impact the safety of not only patients themselves, but also those around them. In this article the authors present the case of an elderly patient on HD with progressive cognitive impairment and combative behavior placing him and others at risk of physical harm. The authors discuss the medical, ethical, legal, and psychosocial challenges to care of such patients who lack decision-making capacity with a focus on variable approaches by regions and culture. This manuscript provides recommendations and highlights resources to assist nephrologists, dialysis personnel, ethics consultants, and palliative medicine teams in managing such patients to resolve conflict.

PMID:
24988063
DOI:
10.1038/ki.2014.231
[Indexed for MEDLINE]
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