title: Management dilemmas in pediatric nephrology: time-limited trials of dialysis therapy.
abstract: Time-limited trials of dialysis have been proposed as a third option in addition to initiation of treatment and comfort-care only in the setting of high uncertainty or discordance between the treating team and child/family or among the treating team.
  
  
  
  The index case was noted antenatally to have severe kidney disease and pulmonary hypoplasia. In light of the guarded, but uncertain prognosis and a lack of consensus among the treating team, as well as between the treating team and the family, a time-limited trial of dialysis was initiated. Six days later the child developed bacteremia due to infection of the dialysis catheter. The treating team felt this was a failure of the trial and that future dialysis should be withheld, the family disagreed.
  
  
  
  A time-limited trial is a problematic option. Providers may be better suited by returning to the dichotomous choice of withholding or initiating treatment.
  
  
  
  • Time-limited trials offer potential benefits in terms of alleviating the burden of decision-making in the setting of uncertainty, offering an opportunity to forecast a poor prognosis, help avoid interprofessional conflict, and providing support for patients, their families, and staff. • Time-limited trials have important limitations, including the use of time limits, difficulty in determining clear, meaningful endpoints, and different interpretations of a trial of therapy between parents and providers. • Decisions regarding the initiation, withholding, and withdrawal of dialysis should be made based on regular assessments of the benefits and burdens of the intervention for the child. • Pediatric nephrologists are better served to abandon the concept of time-limited trials.
authors.affiliation: Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, 98105, USA. Aaron.wightman@seattlechildrens.org.
authors.forename: Aaron
authors.identifier: 0000-0003-0167-0420
authors.initials: A
authors.lastname: Wightman
mesh_terms: D016470:Bacteremia / Q000209:etiology; D019090:Case Management; D055499:Catheter-Related Infections / Q000209:etiology; D002986:Clinical Trials as Topic; D003956:Dialysis / Q000009:adverse effects* / Q000379:methods*; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007674:Kidney Diseases / Q000628:therapy*; D009398:Nephrology / Q000639:trends*; D000070659:Patient Comfort; D017582:Renal Replacement Therapy
keywords: Child; Dialysis; Ethics; Infant; Time-limited trial; Withdraw; Withhold