Decision-making in the implementation or withdrawal of dialysis in the old complex patient

In the last years the population of patients with end-stage renal disease has been growing and the number of patients over 74 years old on renal replacement therapy is rising. However, an increasing number of studies have shown that dialysis is not always associated with a longer life expectancy and a better quality of life for elderly patients with severe chronic comorbidity. Moreover, in selected patients conservative therapy provides a survival and quality of life comparable or even superior to that offered by dialysis. These situations pose new ethical and clinical issues. Nephrologists are increasingly faced with difficult decisions about the optimal therapeutic strategies and what is in the best interest of each patient. The new edition of the Renal Physician Association's guideline on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis takes into account these changes. For this reason the guideline advocates the use of specific parameters and tools for the prognosis assessment in order to identify the classes of patients with very poor prognosis. The importance of discussing the diagnosis, prognosis and treatment options with the patient is emphasized. Shared decision-making is the model for the physician-patient relationship. Treatment options include renal replacement therapy, not starting or stopping dialysis, and continuing medical management or palliative care. Palliative care should be offered to all patients with end-stage renal disease, whether they start or refuse dialysis and whether they continue or withdraw from dialysis. Furthermore, palliative care should be provided throughout the course of the disease, not only at the end of life.