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A CONTROVERSY IN PD |
Humber River Regional Hospital Weston, Ontario, Canada
e-mail: dmendelssohn{at}hrrh.on.ca
This issue of Peritoneal Dialysis International includes an article by Portolés et al. that suggests, based on a large Spanish experience, that lack of a patient's free choice of modality is associated with worse peritoneal dialysis (PD) outcomes, including early mortality (1). The fundamental question of whether patients should be forced into less expensive dialysis modalities is a controversial ethical dilemma for nephrologists. However, like so many other clinical studies in nephrology, this study is imperfect and really only shines some murky light on the fate of patients that fail hemodialysis (HD) and are therefore obliged to do PD for medical reasons.
It seems clear that patients approaching end-stage renal disease can be grouped into several broad categories. Some choose conservative therapy; others are eligible for early transplantation. Of those that wish to live on dialysis, there are some patients that have contraindications to PD and a few with contraindications to HD, but the great majority can do either method. It is this last group that generates the question of whether to force a home dialysis option.
In contrast, the group described by Portolés et al. is different. It seems that these patients were unable to start or continue on HD, and so were obligated to do PD, but to say they were forced (with the implication that this was against their will) is just not correct. The title, the body of the article, the tables, and the figures would be more accurate if the authors had consitently labeled the group as "manditory (or obligatory) referral to PD," as the authors have done in the abstract.
It is important to point out that the analysis by forced choice may or may not have been a prespecified research question. Indeed, the criteria for assigning patients to the forced choice group are not precisely defined at all. Thus, the association described should be considered hypothesis-generating only.
Nonetheless, it is not surprising that patients that are unable to do HD, or that have failed it, do relatively poorly. They are a self-selected subgroup with many negative characteristics that are different from their younger colleagues who have all options open to them. Thus, the real question is, How did they fare when compared to the only other option that was available, which was the discontinuation of dialysis? The blunt truth is that these patients would have been given a stark choice between PD or death, and were almost certainly not forced to choose PD. In this scenario, shorter survival may well be an imperfect compromise, but indeed a better choice than death in days or weeks.
Still, it is worth considering the more controversial question of whether the majority of patients [60% – 78% in recent studies (2–4)] that could do either PD or HD should be forced by nephrologists to do home dialysis because it is less expensive. My answer is clearly that they should not be.
A fair percent of my academic contributions to the nephrology literature relate to issues around dialysis modality distribution. I am a strong proponent of home dialysis as a first therapy for suitable patients (5). I advocate that nephrologists should voluntarily define, and then strive to achieve, an optimal modality distribution that maximizes patient outcomes but minimizes societal costs (6). I believe that suitable patients should be empowered with sufficient information in order to make autonomous decisions, and should be given detailed education about all modality options (7). Home dialysis should then be actively promoted, but it should not be made mandatory. Support for this approach was assessed in a recent survey of Canadian nephrologists (8) (Figure 1). More than 80% of respondents strongly or somewhat agreed that information should be presented in a way that promotes home dialysis for suitable patients. Conversely, fewer than 25% strongly or somewhat agreed that all suitable patients should be obligated to learn home dialysis.
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Forcing suitable (or unsuitable patients) to home dialysis fails the test of improving patient outcomes and will not be less costly either. Especially since patient compliance and motivation are key elements of successful home dialysis, forced patients will no doubt fail frequently, with death and/or expensive hospitalization and transfers to HD highly likely events.
Finally, there is emerging polarization among nephrologists about whether, as individuals or as professional societies, we should consider cost effectiveness in clinical decisions or in guideline development (12,13). While clearly we need to be economically reasonable in our efforts, at the end of the day we are in a uniquely qualified role as our patient's advocate. Our fiduciary duty is to make the best decisions (and/or treatment recommendations) we can for each and every patient. Based on this principle, it would be wrong for individual clinicians and for our professional societies to insist upon mandated pathways just because they are less expensive, when patients are expected to achieve more benefit through alternative therapies. Cost-constraining decisions are the responsibility of payers (and the broader interests of society). Indeed, these third-party decisions may impact upon our clinical choices. However, it is better that they be imposed upon us by others, than for us to willingly take on the role of cost-constraining agent to the disadvantage of our patients.
Unfortunately, guideline development is often performed with cost considerations included. The recent KDIGO guideline harmonization and development process is one example of this. While nephrologists are generally supportive of applying the principles of evidence-based medicine to guidelines and clinical decisions, they simultaneously want access to promising therapies that may not be stringently studied. Complicating this contradictory mindset is the fact that nephrology is a data-impoverished discipline, with very few conclusive randomized controlled clinical studies (14). Applied to nephrology, this paradigm often leads to either no guideline recommendation at all, or to denial of therapies based on cost. Finding a pragmatic and ethical middle ground that includes consideration of all available data, that includes sensible opinion-based recommendations when evidence is lacking, that sets reasonable treatment targets for clinicians, and that elevates patient advocacy above cost considerations is a profound but important challenge for the nephrology community. Grappling with these polarizing imperatives will not be easy but endorsing forced choice of the least expensive modality can only lead us down a very slippery slope.
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DISCLOSURE |
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FOOTNOTES |
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