Dialysis in the elderly, to treat or not to treat?

The population on renal replacement therapy (RRT) currency, but rather describes the approach to probhas become older and beset by more co-morbidity than lems by thinking citizens in a given society and, for was thought possible when dialysis was introduced. each of us, is influenced by our religious beliefs and About half of the stock is over the normal retirement by the different ethical considerations ( libertarian, age, and over the last decade there has been at least a egalitarian, utilitarian) of the society in which we live. four-fold increase in the number of patients entering The Oxford English Dictionary gives a definition of dialysis over the age of 74 years [1]. A growing Medical Ethics first enunciated in 1884—the duty of proportion of the RRT population is over the age of medical men to the public, to each other and to 85 years. themselves in regard to the exercise of their profession. Indeed, RRT could almost be considered as a branch In a given society, for each doctor, these are a subset of geriatric medicine. Viewed in this context, the nature of and influenced by, the ethics of that society. And of an elderly population is germane. Medically it is each doctor will properly be influenced also by his or very heterogeneous. Some individuals remain fit and her religious and other convictions. active into their ninth or tenth decades, whilst others Thus ‘medical ethics’ cannot offer a global solution show evidence of frailty during their early 60s in the either to a particular medical dilemma or to the absence of an acute physical illness ([2] and Table 1). distribution of health-care resources in a given society. The survival of elderly patients on RRT is much In an insurance-funded health-care system, only those shorter than that of younger patients; the annual cost with the insured funds can benefit—a libertarian soluof treating end-stage renal failure (ESRF) is ~2% of tion. In a state-funded system, it is difficult to see how the health-care budget in some developed countries an outcome-based, utilitarian solution can be avoided. and in some countries approximately half of the state’s It is imprecise to consider the decision to offer or expenditure on the health of its citizens is consumed withhold RRT as an ‘ethical’ dilemma. Rather, it is a in the last year of their lives [3]. pragmatic one, to be addressed within the health-care While these considerations may appear to make a system of the society in which it arises. As already case for excluding older patients as such from RRT, stated it is biological and not chronological age which this is hardly acceptable, for it is biological rather than influences the value of RRT to the individual. This of chronological age that determines whether a person becomes more of an issue in the older patient, since will benefit from RRT. co-morbidity is common in the elderly. Eighty per cent The issue of ‘who to treat’ is debated nevertheless, of individuals over 65 years of age have one and 30% and some place it predominantly in an ethical context. three or more chronic illnesses [4,5]. Malnutrition This is difficult, since the term ‘ethics’ is not a universal occurs. Osteoporosis and atherosclerosis are constitutional and may not readily be corrected. More than Table 1. The definition of the ‘fit’ to ‘frail’ elderly adapted from [2] 10% of the elderly show depressive symptoms and these are related to life stresses and physical deficits Fit elderly Frail elderly [6 ] (Table 1). In renal failure, the incidence of co-morbidity is Live independently Yes No even greater. In a recent study [7] in our centre, we Freely mobile Yes No found that 90% of patients over 65 years of age who Regular medication No Yes were on haemodialysis had two or more co-morbidities. Co-morbiditya No Yes Mental deficitb No Yes Cardiovascular, musculo-skeletal and neurological problems predominate (Table 2). These factors are