[Should dialysis be for all? Maybe not].
For the nephrologist the arrival of a growing number of elderly patients with multiple co-morbidities needing to undergo dialysis treatment involves a task that goes well beyond his/her professional capacities. It is necessary to look, as should always be the case in medicine, to man as a whole and to his humanity. Our attention should be addressed to alleviating his/her state of suffering, controlling his/her most troublesome symptoms, and lastly giving back a functional capacity to him/her, whilst preserving a sensibility towards his/her personal, cultural and spiritual sensibilities. It certainly is not easy to evaluate whether, in order to obtain all of this, it is necessary to proceed with dialysis or whether it is better to stop. It is important to reflect together with the patient and his/her relatives and choose instead to undertake a palliative therapy that might turn out to be more suited to the individual case. In patients whose physical conditions are excellent, and in the young, the start of dialysis therapy and the choice to carry out a transplant are beyond doubt. In these cases, the nephrologist's main task is to convince the more hesitant as to how the replacement therapy will be essential for them, their survival and their future prospects. The same can be said for elderly patients who, with the help of predictive statistical models and on the basis of a holistic vision that also takes into account their functional status, age, number and severity of co-morbidities, can be directed towards specific types of replacement therapy. The case of the elderly or non-elderly patient with an elevated degree of co-morbidity, both in numeric terms and in terms of severity, such as to make the management of any form of dialysis treatment extremely complex, is altogether different. Very often it can be envisaged that, with any dialysis treatment, this patient will not achieve any functional recovery, but his/her dialysis life, nonetheless a short one, will be weighed down by recurrent complications and numerous hospital admissions. In this patient, before starting dialysis, it is important to ask oneself serenely what the pros and cons of chronic dialysis therapy are actually going to be. We should evaluate the prognosis, above all in the short-term, and the objective elements that allow us to suppose a reduced survival, often marked by a series of clinical problems that fore-shadow a very poor quality of life. In my opinion, for such patients the nephrologist has the moral duty to talk with the patient if he/she is able to make the decision or, if not, with some of the close relatives, in order to direct the choice towards conservative therapies that do not have such a devastating impact on his/her level of personal suffering and psychological well-being.
Santoro
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U.O.C. di Nefrologia Dialisi Ipertensione, Policlinico S. Orsola-Malpighi, Bologna, Italy. antonio-santoro@aosp.bo.it
D006694:Holistic Health; D006801:Humans; D007258:Informed Consent; D007676:Kidney Failure, Chronic / Q000628:therapy*; D010166:Palliative Care; D011379:Prognosis; D011788:Quality of Life; D006435:Renal Dialysis / Q000379:methods; D012307:Risk Factors