title: Time to Improve Informed Consent for Dialysis: An International Perspective.
abstract: The literature reveals that current nephrology practice in obtaining informed consent for dialysis falls short of ethical and legal requirements. Meeting these requirements represents a significant challenge, especially because the benefits and risks of dialysis have shifted significantly with the growing number of older, comorbid patients. The importance of informed consent for dialysis is heightened by several concerns, including: (1) the proportion of predialysis patients and patients on dialysis who lack capacity in decision making and (2) whether older, comorbid, and frail patients understand their poor prognosis and the full implications to their independence and functional status of being on dialysis. This article outlines the ethical and legal requirements for a valid informed consent to dialysis: (1) the patient was competent, (2) the consent was made voluntarily, and (3) the patient was given sufficient information in an understandable manner to make the decision. It then considers the application of these requirements to practice across different countries. In the process of informed consent, the law requires a discussion by the physician of the material risks associated with dialysis and alternative options. We argue that, legally and ethically, this discussion should include both the anticipated trajectory of the illness and the effect on the life of the patient with particular regard to the outcomes most important to the individual. In addition, a discussion should occur about the option of a conservative, nondialysis pathway. These requirements ensure that the ethical principle of respect for patient autonomy is honored in the context of dialysis. Nephrologists need to be open to, comfortable with, and skillful in communicating this information. From these clear, open, ethically, and legally valid consent discussions, a significant dividend will hopefully flow for patients, families, and nephrologists alike.
authors.affiliation: Departments of Nephrology and.|Palliative Care, St. George Hospital, Sydney, New South Wales, Australia.
authors.forename: Frank
authors.initials: F
authors.lastname: Brennan
authors.affiliation: Faculty of Law, University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Cameron
authors.initials: C
authors.lastname: Stewart
authors.affiliation: Departments of Nephrology and.
authors.forename: Hannah
authors.initials: H
authors.lastname: Burgess
authors.affiliation: Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Sara N
authors.initials: SN
authors.lastname: Davison
authors.affiliation: Sections of Nephrology and.|Supportive Care, West Virginia University School of Medicine, Morgantown, West Virginia.
authors.forename: Alvin H
authors.initials: AH
authors.lastname: Moss
authors.affiliation: Department of Palliative Care, Cecily Saunders Institute, King's College London, London, United Kingdom; and.
authors.forename: Fliss E M
authors.initials: FEM
authors.lastname: Murtagh
authors.affiliation: Division of Nephrology, Tufts University, Springfield, Massachusetts.
authors.forename: Michael
authors.initials: M
authors.lastname: Germain
authors.affiliation: Departments of Nephrology and.
authors.forename: Shelley
authors.initials: S
authors.lastname: Tranter
authors.affiliation: Departments of Nephrology and.
authors.forename: Mark
authors.initials: M
authors.lastname: Brown
mesh_terms: D000066491:Clinical Decision-Making / Q000941:ethics*; D032882:Comprehension; D007722:Health Knowledge, Attitudes, Practice; D006291:Health Policy / Q000331:legislation & jurisprudence; D006801:Humans; D007258:Informed Consent / Q000941:ethics* / Q000331:legislation & jurisprudence; D016743:Mental Competency; D009398:Nephrology / Q000941:ethics* / Q000331:legislation & jurisprudence; D010358:Patient Participation; D057240:Patient Preference; D010361:Patients / Q000331:legislation & jurisprudence / Q000523:psychology; D011050:Policy Making; D011379:Prognosis; D006435:Renal Dialysis / Q000941:ethics*; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D014836:Volition
keywords: Comprehension; Decision Making; Dissent and Disputes; Humans; Informed Consent; Internationality; Nephrologists; Prognosis; Risk Assessment; autonomy; consent; decision making; dialysis; ethics; nephrology; quality of life; renal dialysis; survival