This is from an article written by Ilene Warner-Maron, Ph.D. on August 16, 2013.
Review this article on Annuals of Long-Term Care today!
In 1995, I began working for a organization that provided the educational program necessary for people seeking licensure as nursing home administrators. The administrator of the course, Gordon, was an older man, perhaps in his late 60s. Over the years, we developed a friendship and a common bond in trying to improve the way we prepared nursing home administrators. Over the next two decades, he became increasingly ill, first with Mantle cell lymphoma, then with the sequalae of the chemotherapy used to address his initial tumor and its additional sites, including several tracheostomies and a colon resection. He eventually turned over the program to others, including me.
At age 85, Gordon had inoperable renal calculi that caused a significant impairment in kidney function. Dialysis was discussed as the only option for his impending renal failure. He became non-ambulatory and tired, but still was engaged in the operations of the nursing home administration program from a distance. His functional needs dictated that he and his wife enter a long-term care facility.
The literature suggests, however, that dialysis of elderly nursing home residents may not be the best solution for people like Gordon. Majula Kurella Tamura, a nephrologist at Stanford University, has been researching the effects of dialysis on the functional status of long-term care facility residents. She used the Minimum Data Set scores for activities of daily living during the 3 months prior to the initiation of dialysis and for three months thereafter. At 3 months, functional status was maintained in 39% of residents, however by 12 months, 58% had died. Only 13% of the nursing home residents were able to maintain their pre-dialysis functional status. She concluded that long-term care residents with end stage renal disease had an associated substantial and sustained decline in functional status.
Dr. Tamura suggests that geriatric practitioners address three areas with their elderly nursing home patients in order to determine if the initiation of dialysis is appropriate:
- Don’t limit the discussion to the glomerular filtration rate (GFR), a measure of renal function. Instead, consider that there may be conditions in which dialysis may be the only way to improve a condition such as refractory hyperkalemia or fluid overload that is unresponsive to diuretics. There may be conditions in which the underlying problem of adult failure to thrive or cognitive impairment will not be reversed or improved despite the use of this technology. Under those circumstances and despite the GFR, dialysis may not be appropriate.
- Appreciate the life expectancy of the resident, both the functional age as well as the chronological age. The life expectancy of an 85-year-old on dialysis is 12 months, according to Dr. Tamura’s study.
- Determine the resident’s goals. Is symptom management the focus, avoidance of hospitalization or is the extension of life the principle issue for the individual?
In Gordon’s case, he was aware that he would require dialysis for 4 hours a day, 3 days a week, and that he would need transportation to and from the dialysis unit, reducing the amount of leisure or rehabilitation time in the nursing home. Despite his age, he decided to undergo dialysis and remains on treatment. He is now 86 years old. He is no more functional than he was pre-dialysis. His goal is life extension, at any cost, although he does talk about discontinuing it at some point in the future. He has outlived his wife and one son. He will go back to dialysis tomorrow.
Eastbrook Healthcare Center is proud to provide our residents with staff-assisted hemodialysis treatment options. For more information about our services, please call us at 216-282-9082. Visit our dialysis page to learn more. (https://eastbrookhealth.com/dialysis-center/)