Professional Documents
Culture Documents
Cancer Patients
Michael J. Germain, MD
Department of Medicine, Tufts University, Springeld, Massachusetts
Malignancies are common in CKD patients, and the kidney by the malignancy, or surgical removal of the
incidence is higher than in the general age-matched kidney to remove the malignancy); and 4) a renal
population. Because cardiovascular disease and in- transplant patient with a terminal malignancy.
fection are so prevalent in CKD, especially ESRD In the rst scenario, withdrawal of dialysis (911)
patients, the mortality rate from cancer in ESRD is often the ethical question. In the second and third
patients is lower than the age-matched general pop- scenarios, withholding of dialysis or withdrawal may
ulation due to these competing inuences. Thus, the be the ethical issue. An important ethical aspect is the
relative risk of mortality from cancer is increased in ethical imperative of the clinician to rst, do no
the younger ESRD population and then declines with harm. The clinician has the right and duty not to
age (1,2). order a treatment that will do more harm than good.
Patients with cancer and a need for RRT present Nephrologists often nd themselves in the position of
very difcult scenarios for making clinical decisions, being asked to provide dialysis, by a patient, family, or
and an approach grounded in medical ethical prin- other clinicians, when dialysis may not be in the pa-
ciples can be helpful (37). Medical ethics reect the tients best interest. Many clinicians feel they are re-
culture and time that we are living in and also quired to provide dialysis treatment when the patient
include a religious perspective. This chapter will or health care provider (HCP) requests it. The SDMG
focus on a US perspective that reects the generally (recommendations 5 and 6) clearly state that the cli-
accepted values of our society at the present time. The nician has no such obligation. The clinician should
United States has a wide representation of cultural document these discussions and make it clear that the
and religious values, with many patients who are patient/HCP has the right to transfer care to another
new immigrants from many countries. A discussion clinician. Clinicians should not fear medicallegal
of the different medical ethical approaches from these concerns in this scenario; in reality, these rarely, if
societies is beyond the scope of this discussion, but ever, occur, especially if the SDMG is followed.
the clinician should always inquire from the patient Instead, shared decision-making is the preferred
and family how they want prognosis, goals of care, process where the clinician/care team (SDMG rec-
and end-of-life issues discussed with them. This dis- ommendation 1) and the patient/family/HCP
cussion will rely heavily on the national clinical make a care plan for the patient. The rst step in
practice guideline Shared Decision-Making in the Ap- this process is for the care team to ask, listen, and
propriate Initiation of and Withdrawal from Dialysis, understand the patients understanding of his or her
2nd Ed. (SDMG), in particular the section Ethical condition and values and goals in life. With the pa-
Considerations in Dialysis Decision-Making (8). Six tients explicit permission, the care team then ex-
ethical principles should be strongly considered for plains from their expert perspective the patients
patients with cancer when discussing RRT (Table 1). condition, prognosis, and the risks and benets of
Conicts between respect for patient autonomy the treatment options. Recent qualitative studies
and benecence/nonmalecence often can occur have shown that CKD patients want to know their
with these patients. There are four scenarios where prognosis. However, our experience is such that pa-
the ethical issues of cancer and RRT intersect: 1) tients often do not want a numerical estimate, such
patients with ESRD who develop a terminal malig-
nancy; 2) patients with a terminal malignancy who Correspondence: Michael J. Germain, Department of Medicine,
develop ESRD; 3) patients with a terminal malignancy Tufts University, 100 Wason Avenue, Suite 200, Springeld,
Massachusetts 01107.
who develop AKI (AKI can be caused by the treatment
of the malignancy, obstruction or invasion of the Copyright 2016 by the American Society of Nephrology
Through the process of consensus building, a shared 2 Do other physicians agree or disagree with the attending
decision and treatment plan is agreed on (SDMG recommen- physicians recommendation to withhold or withdraw
dation 4). In a consensus, each party may not get the plan they dialysis?
2 Is the request for dialysis by the patient or legal agent
originally favored, but they may be convinced by hearing the
medically appropriate?
perspectives put forth by others that a different plan is pre- Consultation with ethics committee or ethics consultants.
ferred. Sometimes the party may not like the consensus plan 2 Has the patient or legal agent been informed that the purpose of
but agrees to accept it. I have seen this in situations where the the ethics consult is to clarify issues of disagreement, and ideally,
HCP may want to initiate or continue dialysis in a patient who to enable resolution?
clearly is getting no benet (or even suffering harm), but the 2 Has the patient or legal agent met with the ethics committee or
nephrologist has decided that he or she cannot ethically order ethics consultants to explain their perspective and reasoning
behind their request for dialysis?
the dialysis treatment. After offering to transfer care to another
2 Can the ethics committee identify the reasons why the patient or
nephrologist, invariably the HCP will accept the clinicians legal agent is resistant to the physicians recommendation to
decision. For this to work, the clinician must show respect forgo dialysis?
for the alternative point of view, listen carefully, and validate 2 Can the ethics committee identify the reasons why the health
the persons views. If the views are based on religious objec- care provider is resistant to the patients or legal agents desire to
tions, then it is sensible to involve a clergy person who may begin or continue dialysis?
help explain the religions positions. A time-limited trial of 2 Has the ethics committee explained in understandable terms to
the patient or legal agent its conclusions and the reasoning
RRT (7) can be undertaken in certain dened situations
behind them?
such as when the benet to be achieved by dialysis is uncertain 2 Can the impasse be resolved with accommodation, negotiation,
or a consensus about the benet of dialysis cannot be reached or mediation?
(SDMG recommendation 7). Documentation
When consensus cannot be reached, the SDMG suggests 2 The physician must document the medical facts and his/her
conict resolution (SDMG recommendation 8; resolving reasons for the recommendation to forgo dialysis and the
conicts about what dialysis decision to make; Box 1 and decision not to agree to the request by the patient or legal agent.
2 The consultants should also document their assessment of the
Figure 1). The SDMG suggests a practical ethical approach
patients diagnosis, prognosis, and their recommendations in
to decision-making. The patients case is analyzed from these the chart.
perspectives (Table 2). An attempt to transfer the patients care
Each perspective is viewed through the six ethical principles in 2 If reconciliation is not achieved through the above procedure
Table 1. The SDMG then recommends the following process for and the physician in good conscience cannot agree to the
ethical decision-making (Table 3). Although the SDMG recom- patient or legal agents request, the physician is ethically and
mends that patients with a terminal prognosis (,6 months) legally obligated to attempt to transfer the care of the patient to
another physician.
should not receive dialysis, the guidelines recognize that palli-
2 Another physician and/or institution may not be found who is
ative dialysis (12) is an option for those who require more time willing to accept the patient under the terms of the familys
to nish their life goals. Such goals include activities for signif- request. Physicians and institutions that refuse to accept the
icant events like a wedding, birth, or graduation. Palliative di- patient in transfer and their reasons should also be documented
alysis allows the patient to transition to a more comfort-oriented in the medical record.
care. The patient may shorten their dialysis treatment time, re- 2 Consider consultation with a mediator, extramural ethics
strict further hospitalizations or procedures, and, when appro- committee, or the ESRD Network in the region.
priate, receive hospice services (SDMG recommendation 9).