No resource constraints in dialysis: a blessing and a curse

Driven To Dialysis? A Very Sick Nonagenarian Develops Kidney Failure in Health Affairs is the insightful tale of how the modern US health care system –with its explicit lack of constraints on resource utilization– often steers patients down the more aggressive, expensive path even when that’s not the patient’s preference.

To summarize, an active, but rather ill 95 year old farmer with advanced heart failure was referred to an academic medical center to start emergency dialysis. The author –a hospitalist– questioned the advisability of putting this patient on dialysis at all. It was unclear whether it would increase his life expectancy and there were concerns about quality of life tradeoffs (e.g., spending a couple days a week at the dialysis center), side effects and infections. After the hospital’s kidney team assessed the patient, the hospitalist’s recommendation not to start dialysis was contradicted. The hospitalist spoke with the patient and found he actually didn’t want to be on dialysis. He said:

“In my heart, I don’t want dialysis. I want to go home and be outside with my birds and animals. Please call my wife and tell her this. Thank you.”

Yet despite the hospitalist’s intercession, a variety of forces combined to push the patient to dialysis:

  • The wife seemed in favor of dialysis, to keep her husband busy some days so she could get back to work, and because a 65 year old relative was doing well on dialysis
  • The patient’s nephrologist back home thought it would be a good idea to start dialysis
  • The patient didn’t really feel he had a choice. He thought it was dialysis or death
  • Dialysis is fully covered by Medicare, and health care providers and suppliers earn substantial income from each patient

In this situation, even well-informed patients are likely to end up on dialysis even when they don’t really want to make that decision. From the author’s perspective:

The three days Mr. L spent in our hospital didn’t alter his ultimate course toward dialysis. In fact, it seemed as if his route there was preset… The discussions he had with me and the resident team had been just a detour, not turning away from dialysis as we’d thought, but coming back to the still-set route to treatment. The talks had simply triggered the system to “correct” for the “wrong” turn created by our conversations…

[T]he patient’s voice had been further drowned out by bossy backseat-driver voices from family, financial pressures, and the overall “always treat the disease” viewpoint of the health care system… Would he still have chosen dialysis had all the facts been communicated—and communicated differently—to him and his family?

Although the author is young, she does a good job of bringing in the historical perspective. “It wasn’t always this way,” she points out. When dialysis first became available it was a scarce resource, and hospital committees applied tight criteria to determine which subset of patients would be able to get the treatment. At that time there were plenty of patients who could have benefited from dialysis who didn’t receive it, but I bet there weren’t many who got dialysis who didn’t really need it.

I’m not advocating that we go back to the old system, but I do think we’ve swung too far in the other direction –to the point where excessive utilization is the default decision even when the patient isn’t pushing it.

May 3, 2011

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