Ethical Concerns in the Care of Patients with Advanced Kidney Disease: a National Retrospective Study, 2000-2011

Background Understanding ethical concerns that arise in the care of patients with advanced kidney disease may help identify opportunities to support medical decision-making. Objective To describe the clinical contexts and types of ethical concerns that arise in the care of patients with advanced kidney disease. Design Retrospective cohort study. Participants A total of 28,568 Veterans with advanced kidney disease between 2000 and 2009 followed through death or 2011. Exposure Clinical scenarios that prompted clinicians to consider an ethics consultation as documented in the medical record. Main Measures Dialysis initiation, dialysis discontinuation, receipt of an intensive procedure during the final month of life, and hospice enrollment. Key Results Patients had a mean age of 67.1 years, and the majority were male (98.5%) and white (59.0%). Clinicians considered an ethics consultation for 794 patients (2.5%) over a median follow-up period of 2.7 years. Ethical concerns involved code status (37.8%), dialysis (54.5%), other invasive treatments (40.6%), and noninvasive treatments (61.1%) and were related to conflicts between patients, their surrogates, and/or clinicians about treatment preferences (79.3%), who had authority to make healthcare decisions (65.9%), and meeting the care needs of patients versus obligations to others (10.6%). Among the 20,583 patients who died during follow-up, those for whom clinicians had considered an ethics consultation were less likely to have been treated with dialysis (47.6% versus 62.0%, adjusted odds ratio [aOR] 0.63, 95% CI 0.53-0.74), more likely to have discontinued dialysis (32.5% versus 20.9%, aOR 2.07, CI 1.61-2.66), and less likely to have received an intensive procedure in the last month of life (8.9% versus 18.9%, aOR 0.41, CI 0.32-0.54) compared with patients without documentation of clinicians having considered consultation. Conclusions Clinicians considered an ethics consultation for patients with advanced kidney disease in situations of conflicting preferences regarding dialysis and other intensive treatments, especially when these treatments were not pursued.