title: Ethics and health policy of dialyzing a patient in a persistent vegetative state.
abstract: Each year, out-of-hospital cardiac arrests occur in approximately 300,000 Americans. Of these patients, less than 10% survive. Survivors often live with neurologic impairments that neurologists classify as anoxic-ischemic encephalopathy (AIE). Neurologic impairments under AIE can vary widely, each with unique outcomes. According to the American Academy of Neurology Practice Parameter paper, the definition of poor outcome in AIE includes death, persistent vegetative state (PVS), or severe disability requiring full nursing care 6 months after event. In a recent survey, participants deemed an outcome of PVS as "worse than dead." Lay persons' assessments of quality of life for those in a PVS provide assistance for surrogate decision-makers who are confronted with the clinical decision-making for a loved one in a PVS, whereas clinical practice guidelines help health care providers to make decisions with patients and/or families. In 2000, the Renal Physicians Association and the American Society of Nephrology published a clinical practice guideline, "Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis." In 2010, after advances in research, a second edition of the guideline was published. The updated guideline confirmed the recommendation to withhold or withdraw ongoing dialysis in "patients with irreversible, profound neurological impairments such that they lack signs of thought, sensation, purposeful behavior and awareness of self and environment," such as found in patients with PVS. Here, the authors discuss the applicability of this guideline to patients in a PVS. In addition, they build on the guideline's conception of shared decision-making and discuss how continued dialysis violates ethical and legal principles of care in patients in a PVS.
authors.affiliation: Palliative Care and Internal Medicine, Southeastern Permanente Medical Group, Inc., Atlanta, Georgia;, †Medical Ethics, Grady Health System, Atlanta, Georgia, ‡Nephrology, Atlanta Veterans Affairs Medical Center and Emory University, Atlanta, Georgia.
authors.forename: Anna
authors.initials: A
authors.lastname: Skold
authors.forename: Jason
authors.initials: J
authors.lastname: Lesandrini
authors.forename: Steven
authors.initials: S
authors.lastname: Gorbatkin
mesh_terms: D001291:Attitude of Health Personnel; D002755:Choice Behavior; D003142:Communication; D005195:Family Relations; D019983:Guideline Adherence; D006291:Health Policy; D006801:Humans; D058687:Out-of-Hospital Cardiac Arrest / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D028701:Patient Rights / Q000941:ethics / Q000331:legislation & jurisprudence; D018458:Persistent Vegetative State / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D011050:Policy Making; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000941:ethics / Q000331:legislation & jurisprudence; D011368:Professional-Family Relations; D011379:Prognosis; D011788:Quality of Life; D006435:Renal Dialysis / Q000941:ethics / Q000592:standards; D051437:Renal Insufficiency / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D028761:Withholding Treatment / Q000941:ethics / Q000331:legislation & jurisprudence / Q000592:standards