Is Dialysis Always Justified? Ethics and Economics
Terminally ill patients requiring dialysis present complex ethical and medical dilemma to the nephrologists. With the rising health care costs and futility of care in such cases, the financial burden is a lingering concern. Methods:
We describe a 77-year-old male with lymphoma and prostate cancer admitted for abdominal pain and weight loss. He was found to have metastatic pancreatic adenocarcinoma on laparotomy. His malignancy was deemed inoperable and was offered palliative care. Subsequent hospital course was complicated by sepsis with multiple organ failure resulting in acute renal failure requiring dialysis support. Being aware of his poor prognosis, patient initially declined interventions including dialysis. He was later convinced by his family and agreed to aggressive therapeutic intervention. Anticipating a complicated course, hemodialysis was initiated through cuffed tunneled catheter (CTC). Subsequently, he had multiple episodes of sepsis resulting in removal of CTC, necessitating insertion of 9 temporary dialysis catheters and 3 CTC over a 9-month period; further complicated by thrombosis of both femoral veins. Eventually, patient's condition progressively deteriorated and dialysis was withdrawn with family's consent 9 months following surgery. Patient was put on comfort care and died 2 days later. He spent a total of 7½ months in ICU, 1 month in skilled care facility, and 2 weeks on regular hospital floor. Total VAMC expenditure was $373,964, which in a private setting would be approximately $1.0 million. Conclusion:
This case highlights the futility of aggressive management of renal failure in terminally ill elderly patients. Besides its inability to improve quality of life, it adds as a financial burden to the society.
Document Type: Research Article
Affiliations: Overton Brooks VAMC and Louisiana State University Health Sciences Center, Shreveport, LA, U.S.A.
Publication date: January 1, 2004