Dialysis: destination or journey.

The continued poor survival and diminished quality of life for patients treated with dialysis, particularly elderly individuals, is an important health care issue. In this issue of JASN, Vandecasteele and Kurella Tamura propose a change from a process-driven approach to dialysis care to one that incorporates a realistic assessment, in collaboration with the patient, of the relationship between the treatment goals and future outcomes.1 They argue against the current culture of applying clinical practice guidelines to all patients and challenge the benefits of using biochemical surrogate outcomes. Akin to the revolutionary changes in recent guidelines on cholesterol2 and hypertension3 management, they propose that the renal community should change the focus from directives given to physicians to decision-making that incorporates individual patient preferences. For patients with CKD who might require dialysis, the invasive and lifestyle-changing effect of the therapy makes this drive toward improved shared decision-making imperative. The authors propose that health care providers responsible for thecareof thesepatients shouldoperationalize theproposed new model of care using three patient-centric paradigms. The first and most familiar of these paradigms is labeled “dialysis as a bridge to transplantation or long-term maintenance.” Patients considered to have a good prognosis andwhose goal is transplantation or long-term maintenance dialysis, preferably self-care, would be included in this group. Treatmentspecific goals include adherence to stringent treatment targets, similar to those currently used, with the anticipation that this will lead to better long-term health and a sustained ability to engage in professional and private life functioning. A second identifiable group of patients includes those with a low probability of recovering independent social functioning and those at high risk of imminent death or recurrent hospitalizations. They recommend that these individuals and their families be provided with unbiased information that would allow an informed choice between dialysis therapy and a strategy labeled “active medical management without dialysis.” In practice, this strategy is most applicable to patients with severe dementia and those with poor functional status and high comorbidity. Functional status is an important marker of poor outcomes. Fewer than one third of patients undergoing dialysis and admitted to long-term hospital care ever return home.4 Among 3702 nursing home residents in the United States, all of whom had high baseline dependency levels, dialysis initiation was associated with further significant functional decline and a 1-year mortality rate of 58%.5 Had these elderly individuals been offered a fully informed option for maximal conservative therapy, would their outcomes have differed? The data are limited to several singlecenter observational studies, each with unique flaws. The largest of these, from the United Kingdom,6 compared the survival of 29 patients (median age, 81.6 years) who chose maximal conservative therapy with that seen in 173 patients (median age, 76.4 years) starting RRT. Although the median unadjusted survival duration was only 13.9 months for the maximal conservative therapy group compared with 41.9 months for the RRT group, the former required fewer days, per patient-year survived, in the hospital (16 days compared with 25) andwere four timesmore likely to die at home or in a hospice compared with those starting RRT. Despite these data, it remains unclear what is “best.”7 The cultural shift within medicine toward patient-centered care8 leaves many questions unanswered. We know little of the patients’ experiences, their satisfaction with their lives, or the socioeconomic costs of nondialysis care. Some answers may be provided by an ongoing prospective observational study of dialysis and predialysis patients aged 65 years or older.9 This study will address not only survival but also health-related quality of life, economic burden, and comorbidity. The circumstances under which the elderly initiate longterm dialysis must also be considered. Among 416,657 Medicare beneficiaries age 67 years or older, long-term dialysis was initiated in an inpatient setting in 64.5%; most patients (96.2%) survived to discharge. The patients were divided into five groups, one with outpatient initiation and four defined according to increasing intensity of inpatient care. Themedian duration of survival of those initiating dialysis as an outpatient was 2.1 years compared with 0.7 years in the group with the most intensive inpatient care.10 Formany of these patients, the discussion that incorporates their preferences will occur after dialysis has been initiated in the setting of AKI. A third paradigm proposed is “dialysis as a final destination.” Although it is the most likely to be controversial, it is consistent with patient-centered care and personalized medicine. It is also widely applicable to the most vulnerable of our dialysis patients. The authors’ recommendation is that Published online ahead of print. Publication date available at www.jasn.org.