From the Guidelines
This is normal and relatively common. Patients often change their minds about end-of-life care decisions when faced with the immediate reality of their situation, even after previously expressing different preferences. This patient had previously indicated a preference for supportive care over dialysis, but when confronted with the actual symptoms of his end-stage renal disease and congestive heart failure, he reconsidered his options. This change of mind is a normal part of the decision-making process for many patients with serious illness, as noted in a study published in the Journal of Clinical Oncology 1. It reflects the difficulty in predicting how one will feel when actually experiencing a health crisis versus contemplating it hypothetically.
Key points to consider in this situation include:
- The patient's values and preferences may have evolved over time, and it is essential to have ongoing discussions to clarify his current goals and priorities.
- The benefits and burdens of dialysis should be carefully weighed, taking into account the patient's multiple comorbidities, such as ischemic cardiomyopathy, emphysema, and peripheral vascular disease.
- Healthcare providers should approach this situation with empathy and understanding, recognizing that changes in preferences are a normal part of the decision-making process for patients with serious illness, as highlighted in a study published in the Journal of Clinical Oncology 1.
- Advance care planning is not a one-time event, but rather an ongoing process that requires regular reassessment and updating to ensure that the patient's wishes are respected and his needs are met.
In this context, the patient's decision to start dialysis, despite his previous preference for supportive care, should be respected and supported, while also ensuring that he has accurate information about the potential benefits and burdens of this treatment option.
From the Research
Analysis of the Situation
- The patient, a 79-year-old man with ischemic cardiomyopathy and multiple comorbidities, has expressed a desire to start dialysis despite previously stating a preference for supportive care over dialysis.
- This change in decision is not uncommon, as studies have shown that patients' preferences and expectations can evolve over time 2.
- The patient's decision to start dialysis may be influenced by various factors, including his current health status, symptoms, and quality of life.
Relevant Studies
- A study published in JAMA Internal Medicine found that clinicians often have an "all-or-nothing" approach to caring for patients with advanced chronic kidney disease, with initiation of dialysis serving as a powerful default option 3.
- Another study published in BMC Medical Ethics highlighted the importance of individualized decision-making and patient-centered care in the context of dialysis initiation, particularly for elderly patients with complex medical conditions 4.
- A review published in JAMA noted that decisions about dialysis initiation timing and modality should be influenced by patient symptoms, laboratory trajectories, patient preferences, and therapy cost and availability, and should include shared decision-making 5.
Patient Perspectives
- A qualitative study published in International Urology and Nephrology found that elderly patients starting dialysis often have unrealistic expectations from treatment and may not be fully informed about the risks and benefits of dialysis 2.
- A survey published in Clinical Nephrology found that many dialysis patients wish to have more frequent discussions about their disease, prognosis, and end-of-life planning, and may regret their decision to start dialysis 6.