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Abstract
Objectives: To study factors influencing the recommendation for palliative (non-dialytic)
treatment in patients approaching end-stage renal failure and to study the subsequent
outcome in patients choosing not to dialyse. Design: Cohort study of patients approaching
end-stage renal failure who underwent multidisciplinary assessment and counselling
about treatment options. Recruitment was over 54 months, and follow-up ranged from
3 to 57 months. Groups were defined on the basis of the therapy option recommended
(palliative or renal replacement therapy). Setting: Renal unit in a district general
hospital serving a population of about 1.15 million people. Subjects: 321 patients,
mean age ± SD 61.5 ± 15.4 years (range: 16–92), 57% male, 30% diabetic. Main Outcome
Measures: Survival, place of death (hospital or community). Results: Renal replacement
therapy was recommended in 258 patients and palliative therapy in 63 (19.6%). By logistic
regression analysis, patients recommended for palliative therapy were more functionally
impaired (modified Karnofsky scale), older and more likely to have diabetes. The comorbidity
severity score was not an independent predictor. Thirty-four patients eventually died
during palliative treatment, 26 of whom died of renal failure. Ten patients recommended
for palliative treatment opted for and were treated by dialysis. Median survival after
dialysis initiation in these patients (8.3 months) was not significantly longer than
survival beyond the putative date of dialysis initiation in palliatively treated patients
(6.3 months). 65% of deaths occurring in dialysed patients took place in hospital
compared with 27% in palliatively treated patients (p = 0.001). Conclusions: In
high-risk, highly dependent patients with renal failure, the decision to dialyse or
not has little impact on survival. Dialysis in such patients risks unnecessary medicalisation
of death.