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Presentation Slides & Transcript

Presentation Slides & Transcript


Ethics in Hemodialysis
Professor/ Ahmed Abd El Hady
FRCP- Edinburgh
Prof of Int Medicine & Nephrology
Military Medical Academy

Scenario I
Mr./ M. 87 year male suffer from dementia on and off daily phenomenon with severe furious attack.
Presented to hospital with fever and rigor
He has had apart of dementia a good general condition and good cardiac condition.

Investigations revealed : UTI, and impaired kidney functions:
creatinine: 5 mg/dl, history revealed that creatinine increased 2 years ago with family incompliance and no medical consultations was done at that time.

After treatment of the UTI for 10 days the general condition was back to base with Creatinine: 5.5 mg/dl
Counseling with family about future need to dialysis was carried out and they refuse dialysis at any stage in the future.

After 3 months, the patient return back in the same condition with Creatinine: 7.5 mg/dl, pH: 7.2-7.3
Back to the family previous decision and with absence of his elder son we were stuck !!!...... to dialyse or not ?

Considering that the patient passing urine and k :4.8 mg/dl
His son return back insisting to do dialysis to his father but he cant bring his father 3 times / week and actually the patient come twice or once weekly.

Scenario 2
Female patient 75 year old presented with delirium, abdominal pain and oliguria
Examination & investigations revealed
Urea :280 mg/dl
Creatinine: 8.5 mg/dl
K : 7.5 meq/l

starting 3 dialysis session
ultrasound was done: revealed abdominal mass most probably in the transverse colon.
Chest and abdomen contrast CT arranged revealing mass in the left colon with measurement of 2*7 and urinary bladder mass with mild degree left hydronephrosis and highly suspicious metastatic liver nodule

when Creatinine reach:2.5 mg/dl we Stopped dialysis but rapid increase in Creatinine to 7mg/dl occur again after 3 days, so the patient should be on regular dialysis.
the surgeon decision was inoperable condition and the oncologist refuse managing the case with no diagnosis on pathology base and advance metastasis
Is that case should be managed by nephrologists or not?

Scenario 3
50 year old male diabetic since 7 years presented to cardiology centre with severe chest pain.
Failed thrombolysis, the patient has been candidate for urgent PCT.
The patient investigations before the coronary angio:
Urea: 37mg/dl
Creatinine:0.6 mg/dl

After the Angio
The patient got oliguria with rapidly increasing Creatinine level that reach: 1.7 mg/dl & urea: 89 mg/dl
The patient still oloiguic more than 24 hours with creatinine increase to 2.5 mg/dl & urea 107 mg/dl & K:7 meq/l
RBS:150 mg/dl

The Angioplasty was successful .
Which type of RRT will you choose for this patient?
Conservative and follow up
Veno-venous HD

It is a time consuming and physical burden for patients with ESRD.
Some patients may eventually decide that this burden overweighs the benefits and then wish to discontinue treatment.

Discontinuing dialysis is considered an appropriate treatment option that respects a patient’s autonomy and ability for self direction.
Ethical challenges arise when stopping dialysis becomes an option a patient want to consider.

AUTONOMY- the right to choose for oneself what one believes to be in one’s best interest.
BENEFICENCE- is the duty to benefit others.
NON-MALEFICENCE- is the duty to do no harm and to protect others from harm.

Although consensus can usually be achieved, conflict between families and caregivers may prevent effective decision-making.
Factors that contribute to conflict include mistrust, miscommunication, misconceptions about critical care, certain religious& believes, and strife within the family.

Fourth, busy clinicians may delegate too much responsibility to inexperienced
housestaff, whose opinions are less valued by the family. Other obstacles include
frequent changes in the attending physician, perceptions of conflict among the staff, a
perceived need to “free up” beds for other patients, and concern that the physician is not
an enthusiastic advocate for the patient. Finally, families may be reasonably concerned
that patients who made “do not resuscitate” (DNR) orders will have other interventions
52 Fins

Failure to build trust may lead families to doubt prognostic estimates and to resist treatment recommendations. Several factors may contribute to mistrust. First, true or not, families may question the quality of care being provided and whether all treatment options have been explored, in turn making it difficult for them to believe reports that treatment has failed. Second, families sometimes report past experiences in which patients survived after being told there was no hope, thus causing them to doubt
subsequent prognostic estimates. Third, concerns about racial disparity may lead minority families to question the motivation to recommend withholding or withdrawing LST.

there is a need for consensus or guidelines to regulate when to end or continue dialysis and whom are patients to tell enough is enough

Who decides?

In the absence of a living will or an advanced directive, and a surrogate isn’t designated, the choice whether to withhold or withdraw life support falls to the next of kin, according to law.

Code of Medical Ethics
In 1847 the American Medical Association revolutionized medicine in the United States. This code of ethics is a touchstone for medicine as a professional community.
Medical ethics, as a branch of general ethics, must rest on the basis
of religion and morality. They comprise not only the duties, but, also, the
rights of a physician.
The AMA Code of medical Ethics states that, "A competent adult patient, may in advance, formulate and provide a valid consent to the withholding and withdrawing of life support systems in the event that injury or illness renders that individual incompetent to make such a decision.”

1. Stopping dialysis should occur when patients are either:
Capable of decision-making and decide to forgo dialysis
A written health care directive expresses a desire to discontinue dialysis
A health care agent considers discontinuation of dialysis as the best course of action
When a physician decides dialysis is no longer beneficial.

2. Shared decision making between the patient and the physician must occur, and if the patient lacks decision-making capacity, the health care agent should be involved.

3. Physicians should provide patients with all available information including available treatment options, consequences of dialysis withdrawal and other end of life care options and palliative care.

Are physicians legally required to provide all life-sustaining measures possible?
No. To the contrary, patients have a right to refuse any medical treatment, even life-sustaining treatments such as mechanical ventilation, or even artificial hydration and nutrition.

Islamic rules in HD ethics
Kidney replacement therapyare performend to replace non functioning or diseseased kidneyes
Like many other medical procedures HD is permissable in Islam because it is a treatment of medical condition

This is consistent with the rule stated by Allah S.W.T in Holly Quran
?? ??? ???? ???? ??? ?? ????? ?? ????? ?????? ??? ????? ????? ? ?? ?????? ?????? ???? ????? ?????
which means: “[U]nless it be for murder or for spreading mischief in the
land – it would be as if he slew the whole people: and if any one saved a life,
it would be as if he saved the life of the whole people.”1

Incidence and outcome of patients starting renal replacement therapy for end-stage renal disease due to multiple myeloma or light-chain deposit disease: an ERA-EDTA Registry study 2009
Conclusion: The incidence of RRT for ESRD due to MM or LCDD has increased over the past 20 years in Europe.
The median patient survival on RRT for MM and LCDD patients was 0.91 year, compared to 4.46 years for non-MM patients. These results suggest that dialysis, and in selected cases even transplantation, should be offered to MM and LCDD patients.

Renal Impairment in Patients With Multiple Myeloma: A Consensus Statement on Behalf of the International Myeloma Working Group 2011 by American Society of Clinical Oncology

Bortezomib with high-dose dexamethasone is considered as the treatment of choice for such patients.
There is limited experience with thalidomide in patients with myeloma with renal impairment.

which means: “Allah has given a cure for all illnesses.” (Hadith narrated
by al-Bukhari)
Say: “To whom belongeth all that is in the heavens and on earth?” say:
“To Allah. He hath inscribed for Himself mercy.”
(Al-An’am: 12)

Is withdrawal or withholding of treatment equivalent to euthanasia?
No. There is a strong general consensus that withdrawal or withholding of treatment is a decision that allows the disease to progress on its natural course. It is not a decision to seek death and end life. Euthanasia actively seeks to end the patient's life.

Are you killing the patient when you remove the ventilator and treat the pain?
No. The intent and sequence of actions are important, as are the means chosen. If the intent is to secure comfort, not death; if the medications are chosen for and titrated to the patient's symptoms; if the medications are not administered with the primary intent to cause death, then ventilator withdrawal and pain treatment are not euthanasia.

Can the treatment of symptoms constitute euthanasia?
No. For patients who have been using opioids for pain, it is very difficult to give such high doses that death is caused or even hastened in the absence of a disease process that is leading to imminent death. Patients tend to sleep off the effect if they receive too much medication. However, in the rare circumstance when opioids might contribute to death, provided the intent was genuinely to treat the symptoms, then opioid use is not euthanasia.

Outline the patient’s own goals and wishes regarding medical care
Provides specific instructions about treatments, including do-not-resuscitate orders, organ donation, palliative care, feeding tubes, etc.
Designate power of attorney to a healthcare decision maker who will speak for the patient should he or she become unable to communicate

Aims to honor individual autonomy, respect individual choice and prevent situations in which a patient is given treatment he or she would not have wanted.

Situations in Which It Is Ethically Appropriate to Forgo Dialysis
  Patients with decision-making capacity who, being fully informed and making voluntary choices, refuse dialysis or request that dialysis therapy be discontinued
Patients who no longer possess decision-making capacity who previously have indicated refusal of dialysis therapy in an oral or written advance directive
Patients who no longer possess decision-making capacity and whose properly appointed legal agents/surrogates refuse dialysis therapy or request that it be discontinued
Patients with irreversible profound neurologic impairment such that they lack signs of thought, sensation, purposeful behavior, and awareness of self and environment
Note: Reproduced from Renal Physicians Association (RPA) guideline 22 (available at with permission of the RPA.

These recommendations, which are based on a clinical practice guideline from the Renal Physicians Association (RPA) entitled Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, describe the underlying ethical principles as "respect for beneficence, nonmaleficence (do no harm), patient autonomy, justice, and professional integrity." [22(p19)] 

When enough is enoughAm J Kidney Dis. 2011;58(1):135-143.  2011 
These recommendations, which are based on a clinical practice guideline from the Renal Physicians Association (RPA) entitled Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, describe the underlying ethical principles as "respect for beneficence, nonmaleficence (do no harm), patient autonomy, justice, and professional integrity." [22(p19)] Specifically, the ethical principles of beneficence and nonmaleficence mandate that health professionals provide only treatments that offer a reasonable expectation of benefit without unacceptable harm. Patient autonomy implies that every person has the right to self-determination with the view that the patient usually is the best person to make his or her own health care decisions. Dialysis therefore should be provided only if it is reasonably likely to achieve the individual patient's goals. In situations in which dialysis will not reach these goals, care should shift to a more palliative approach that focuses on treating symptoms and preserving function.

s 77-year-old with congestive heart failure and diabetes. She had her first coronary artery bypass graft (CABG) surgery 12 years ago and underwent a second CABG in January. Five days after the repeat CABG, Ms Petry experienced a cardiac arrest. Although CPR was effective in reestablishing her cardiac rhythm, she developed renal failure and now requires hemodialysis. She spent months in and out of the intensive care unit with various complications including pneumonia, decubitus ulcers,Clostridium difficile, and difficulty weaning from the ventilator. In May, she is transferred to an assisted-living facility with outpatient hemodialysis treatment. During her new client orientation to the dialysis center, Ms Petry told the nurse, "I was coded once, and I never want to go through that again!" After hearing Ms Petry's treatment preferences, the dialysis nurse asks the dialysis center nurse manager, "Isn't dialysis a life-sustaining treatment? Is it ethical to do dialysis but not CPR?"
After learning about these 2 different patient events, the nurse manager realizes that the dialysis nursing staff is raising thoughtful questions related to not only the clinical goals of dialysis, but also legal and ethical concerns

enacted as federal law in 1991, grants all persons or their surrogates the right to refuse or discontinue treatment, and it makes advance directives completed in any state legal and portable. This same law also requires all medical facilities receiving federal funds to ask, at the time of admission, whether a prospective patient has completed a written advance directive, which usually includes the naming of a surrogate decision maker. Nursing facilities must document at regular intervals whether a resident has an advance directive or has designated a surrogate decision maker.11

One might think that it would be a fairly simple issue of abiding by the patient's preferences; both the Patient Self-determination Act
10 and the National Kidney Foundation's12 Dialysis Patients' Bill of Rights and Responsibilities are about respect for patient autonomy. However, as of 2003, only 6% to 35% of chronic dialysis patients have completed written advance directives.3And although 67% to 77% of dialysis patients have discussed their wishes about life- sustaining treatment with their families or someone close to them, researchers have found that patients often do not have clear, reliable data with which to make these determinations, and many patients who claimed to want CPR during an acute illness changed their mind after learning the probability of survival to discharge.3 This full disclosure fulfills the principle of informed consent, which requires that the decision maker understand not only the problem, but also the pros and cons associated with the available options. Respect for patient autonomy does not equal respect for any choice: respect for patient autonomy is respect for the informed decisions that a patient makes.3

A patient's desire to have a DNR order while concurrently receiving hemodialysis is not ethically inconsistent, but rather reflects a clear understanding and integration of the patient's values and beliefs and the specific goals for dialysis treatment. Nurses have an ethical obligation to assist patients to explore their values and beliefs and to execute an advance directive if desired. Transparent agency policies and open honest communication between the dialysis staff and patients and their significant others should promote a mutual trusting relationship.


1. Alport Syndrome Foundation. What is Alport syndrome? 2010.
/. Accessed February 22, 2011. [Context Link]
2. Norris K. Why do I feel nauseous and lethargic after dialysis? 2002.
/. Accessed March 25, 2011. [Context Link]
3. Ross LF. Do not resuscitate orders and iatrogenic arrest during dialysis: should "no" mean "no"? Semin Dial. 2003;16(5):395-398.
4. Moss AH, Holley JL, Davison SN, et al. Core curriculum in nephrology: palliative care. Am J Kidney Dis. 2004;43(1):172-173.
5. Ebell MH, Becker LA, Barry HC, Hagen M. Survival after in-hospital cardiopulmonary resuscitation: a meta-analysis. J Gen Intern Med. 1998;13(12):805-816.
6. Moss AH, Holley JL, Upton MB. Outcomes of cardiopulmonary resuscitation in dialysis patients. J Am Soc Nephrol. 1992;3(6):1238-1243.
7. National Kidney Foundation. When stopping dialysis is your choice: a guide for patients and their families. 1989-2006.
. Accessed March 22, 2011. [Context Link]

8. Robert Wood Johnson Foundation. Promoting excellence in end-of-life care: quality of life.
. Accessed March 22, 2011. [Context Link]
9. Kidney End of Life Coalition. Personal death awareness exercises.
. Accessed March 22, 2011. [Context Link]
10. Omnibus Budget Reconciliation Act of 1990. H.R. 5835.ENR.]
11. American Medical Directors Association (AMDA). White paper on surrogate decision-making and advance care planning in long-term care.
. Accessed March 24, 2011. [Context Link]
12. National Kidney Foundation. Dialysis patients' bill of rights and responsibilities. 2003, 2006.
. Accessed February 9, 2011. [Context Link]
13. O'Keefe ME. Nursing Practice and the Law: Avoiding Malpractice and Other Legal Risks. Philadelphia, PA: FA Davis Company. 2001.
14. O'Mathuna DO. Trust and clinical research. Res Pract. 2009;10(5):170-180.

15. American Nurses Association. News release: Gallup poll votes nurses most trusted profession. December 9, 2009.
. Accessed March 26, 2011. [Context Link]
16. Jones JM. Nurses top honesty and ethics list for 11th year. December 3, 2010.
. Accessed March 26, 2011. [Context Link]
17. Whitbeck C. Trust. In Post S, ed. Encyclopedia of Bioethics.3rd ed. New York: Macmillan Reference USA; 2004:2523-2529.
18. Richard C., Lajeunesse Y., Lussier MT. Therapeutic privilege: between the ethics of lying and the practice of truth. J Med Ethics. 2010;36:353-357.
19. Robert Wood Johnson Foundation. Promoting Excellence in End of Life Care Program. 2002.
. Accessed March 12, 2011. [Context Link]

Reaching a decision about dialysis therapy is a matter of informed consent or refusal. Physicians need to disclose the patient's condition and the benefits and risks of treatment options, including active medical management without dialysis. Patients with decision-making capacity (or their legal agents if they lack capacity) then may use this information to decide what treatment they want based on their values.
According to state and federal case law and the federal Patient Self-Determination Act, [35] competent patients have an unconditional right to consent to or decline medically indicated treatment. Authoritative nephrology and psychiatry opinion supports the notion that patients who choose to forgo dialysis therapy typically are neither psychopathologic nor suicidal, although depression may be present. [36]The RPA clinical practice guideline on shared decision making is designed to assist nephrologists, patients, and families in reaching decisions on whether to initiate or stop dialysis therapy. [22]