title: Ethical challenges with hemodialysis patients who lack decision-making capacity: behavioral issues, surrogate decision-makers, and end-of-life situations.
abstract: Hemodialysis (HD) is routinely offered to patients with end-stage renal disease in the United States who are ineligible for other renal replacement modalities. The frequency of HD among the US population is greater than all other countries, except Taiwan and Japan. In US, patients are often dialyzed irrespective of age, comorbidities, prognosis, or decision-making capacity. Determination of when patients can no longer dialyze is variable and can be dialysis-center specific. Determinants may be related to progressive comorbidities and frailty, mobility or access issues, patient self-determination, or an inability to tolerate the treatment safely for any number of reasons (e.g., hypotension, behavioral issues). Behavioral issues may impact the safety of not only patients themselves, but also those around them. In this article the authors present the case of an elderly patient on HD with progressive cognitive impairment and combative behavior placing him and others at risk of physical harm. The authors discuss the medical, ethical, legal, and psychosocial challenges to care of such patients who lack decision-making capacity with a focus on variable approaches by regions and culture. This manuscript provides recommendations and highlights resources to assist nephrologists, dialysis personnel, ethics consultants, and palliative medicine teams in managing such patients to resolve conflict.
authors.affiliation: 1] Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA [2] Division of General Internal Medicine, Section of Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Molly A
authors.initials: MA
authors.lastname: Feely
authors.affiliation: 1] Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA [2] Division of Nephrology Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Albright
authors.affiliation: 1] Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA [2] Division of Primary Care Internal Medicine Mayo Clinic, Rochester, Minnesota, USA [3] Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery and Bioethics Research Program, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Björg
authors.initials: B
authors.lastname: Thorsteinsdottir
authors.affiliation: Center for Health Ethics and Law, Section of Nephrology, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, West Virginia, USA.
authors.forename: Alvin H
authors.initials: AH
authors.lastname: Moss
authors.affiliation: 1] Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA [2] Division of General Internal Medicine, Section of Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA [3] Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery and Bioethics Research Program, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Keith M
authors.initials: KM
authors.lastname: Swetz
mesh_terms: D000369:Aged, 80 and over; D000374:Aggression; D014150:Antipsychotic Agents / Q000008:administration & dosage; D003072:Cognition Disorders / Q000150:complications / Q000523:psychology*; D003657:Decision Making / Q000941:ethics*; D005190:Family; D017809:Fatal Outcome; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000628:therapy*; D007872:Legal Guardians; D008297:Male; D016743:Mental Competency / Q000331:legislation & jurisprudence; D017008:Negotiating; D057240:Patient Preference; D026684:Personal Autonomy; D006435:Renal Dialysis / Q000941:ethics* / Q000379:methods; D012449:Safety; D013727:Terminal Care / Q000941:ethics / Q000331:legislation & jurisprudence
chemical_list: D014150:Antipsychotic Agents