Dialysis prolongs survival, but it also imposes burdens — like traveling to a clinic three times a week for four-hour sessions of hemodialysis, or doing multiple fluid exchanges daily for peritoneal dialysis, which can be performed at home. Conservative management can help patients avoid those routines.
Moreover, while some studies show that older patients undergoing dialysis survive longer than those using conservative management, those differences fade among people over age 75 who also contend with other serious health problems, as most do.
And survival, of course, is not the only thing patients value. Conservative management may allow greater freedom to pursue what matters to them, even if they live fewer weeks or months.
“Dialysis is a life-changing event,” Dr. Susan Wong, a nephrologist at the Veterans Affairs Health Services Research and Development Center in Seattle, and lead author of a new study in JAMA Internal Medicine. “It’s a very demanding form of treatment. It involves medical issues, spiritual issues, quality of life. It’s a big decision.”
Yet patients often tell researchers that they don’t recall making a decision, or even discussing one. Physicians frequently present dialysis as inevitable; in a small study of nephrologists, only a third routinely informed patients about conservative management.
“Patients didn’t recognize it as a choice — ‘My doctor told me I’d die if I didn’t do dialysis,’” said Keren Ladin, director of an aging and ethics program at Tufts University, who has interviewed both patients and nephrologists. “Or they’d say that it wasn’t their choice, that their doctor made the choice.”
Those patients might have wanted to know, for example, that at the end of life, patients using conservative management were less likely to be hospitalized than dialysis patients, less apt to undergo aggressive procedures, and less likely to die in a hospital.
