Ethical and Legal Obligation to Avoid Long-Term Tunneled Catheter Access

The Risks of TCCs

Since their development as an alternative to acute hemodialysis vascular access in the late 1900s, TCCs have generated controversy in the nephrology literature (8,9). TCCs are used as a bridge access device while awaiting maturation of an AVF in patients with severe comorbidities such as congestive heart failure and severe peripheral vascular disease, in the very elderly, in those with inadequate vascular anatomy, in those with limited life expectancy, and as a last resort in patients with multiple access failures (3). Originally hailed as a viable alternative to the arteriovenous graft (AVG), TCCs were presumed to have comparable infectious and thrombotic complication rates for patients needing long-term vascular access in whom creation of an AVF was not possible (10).

However, TCCs have been found to be associated with as much as a threefold increased mortality compared with AVFs (11,12). Sepsis-related death is 100 times greater in dialysis patients than in the general population, with infection-related death and all-cause mortality being highest in those with TCCs (6). Twenty-two percent of patients dialyzing through TCCs develop osteomyelitis, septic arthritis, and endocarditis and progress to death, regardless of whether the TCC is removed or exchanged (13,14). The cost of placing a TCC is approximately $13,000, and that of treating one TCC-related episode of bacteremia is as high as $45,000 (6). A several-fold increase in cardiovascular risk is also noted with TCCs (6).

Poor quality of life, reduced dialysis adequacy, and central venous stenosis that may preclude subsequent AVF creation have also been noted as consequences of TCC use (6). Compounding these problems is a primary TCC failure rate of 52% to 91% per year (5).

Why Is There an Increase in the Number of TCC Placements?

A perceived difficulty in creating AVFs has contributed to the preferential use of TCCs (15). However, creation of AVFs in most patients–probably more than 75%–has been shown to be an attainable goal (16–18). Yet boosting the prevalence of AVFs will require both increased predialysis placement of AVFs and concerted efforts to salvage immature or dysfunctional AVFs with radiologic or surgical interventions (19). The changing demographics of incident ESRD patients caused by the rising rates of diabetes along with the increase in patients older than 75 yr has led to a patient population with enough comorbidities to make TCC an easier alternative for initiation of dialysis. Female sex, obesity, peripheral vascular disease, age older than 65 yr, and preference of the dialysis unit are all independently associated with increased use of TCCs (6).

In addition to patient demographics, lack of a coordinated effort on the part of healthcare professionals constitutes a major reason for the increased prevalence of TCCs as hemodialysis vascular accesses. Late referral to a nephrologist often results in the need for urgent dialysis, necessitating TCC placement (20). Patients with a timely referral to a nephrologist and subsequently to a vascular surgeon still may not have a functioning AVF, as result of either a delay in procedure scheduling or failure of the fistula to mature (6). Allon et al. showed that fistula creation could be increased from 33% to 69% in new dialysis patients using a multidisciplinary approach aided by an access coordinator (21).

Are Patient Choices Contributing to TCC Use?

Few studies address patient preferences that affect the type of permanent access they use. In one study that explicitly did so, the researchers found that significantly more patients using an AVF would recommend it to a friend (77%) than patients using a TCC (62%), and that significantly fewer patients using an AVF (11%) wanted to switch to another access than patients using a TCC (32%). However, significantly more patients using a TCC (97%) considered their access easy to use than patients using an AVF (86%). A minority of patients (12% to 22%) dialyzing through an AVF were at least moderately bothered by pain, bleeding, bruising, and/or appearance. Older patients were more likely to report more symptoms with catheters than younger patients (22). As many as 9% of patients offered an AVF consistently refused surgery, and hesitancy to undergo access surgery in the face of failed prior accesses also deters patients from having a fistula created or revised (23).

The likelihood of converting to a more permanent form of access decreases with increasing duration of catheter use. The Clinical Performance Measures Project reported that 67% of patients who initiated dialysis with a catheter remained catheter-dependent at 90 d (23). This, coupled with the finding that fistula failure was noted to be greater in patients who were already dialyzing through TCCs (24), underscores the importance of adequate education of patients with regard to vascular access before the initiation of dialysis and follow-through to ensure that fistula placement and maturation have occurred.

Nephrologists’ attitudes and perception of vascular access, however, are even less well researched. The Quality Initiative report of 2001 noted the failure of nephrologists to act as Vascular Access Team Coordinators as the topmost barrier to creation of AVFs. After educational meetings, nephrologists were more likely to attempt AVF creation in the elderly, diabetics, obese, and those with failed prior accesses (25).

Should We Respect Patient Choice to Defer an AV Fistula?

Placement of vascular access is a matter of informed consent. On the basis of medical evidence, patients should be informed of the following about long-term dialysis with TCCs compared with AVFs: (1) their risk of death is increased two- to threefold; (2) their risk of serious infection is increased five- to 10-fold; (3) their risk of experiencing a painful complication from infection (osteomyelitis, septic arthritis, endocarditis, or epidural abscess) that may require major surgery and be difficult or impossible to cure is significantly increased; (4) their risk of needing access replacement is higher for TCCs because TCCs are not intended for permanent use; (5) their risk of being sicker because of inadequate dialysis through a TCC is higher; (6) their risk of spending more time in the hospital is higher because of TCC complications; and (7) their risk of death in the first year of dialysis is significantly increased with TCC use. Nephrologists need to be aware of the strength and implications of these data before discussing dialysis access with their patients, and they need to develop the conviction that TCCs are not a safe long-term vascular access option for their patients who are good candidates for an AVF or AVG and that they should not be presented as such. If, for reasons beyond nephrologists’ control, a TCC is required for the initiation of dialysis, patients and families should be informed that TCCs are temporary and unsafe for long-term use in patients who are candidates for a properly functioning AVF or AVG.

Data extracted from the United States Renal Data System Dialysis Morbidity and Mortality study indicated that patients who were more informed and had more proactive nephrologists were more likely to have AVFs placed (26). Failure to adequately inform patients about the benefits and risks of TCCs is confounded by the belief that it is necessary to respect patient choices. Although this may be true with limited exceptions, patients cannot make truly autonomous decisions if they are not adequately informed. Many dialysis patients who choose a TCC long-term may not have been systematically and emphatically informed of the above risks associated with TCC use.

The principle of autonomy, which allows patients to refuse any procedure or choose among different beneficial procedures, does not allow them to demand treatments in which the harms significantly outweigh the benefits (27). The moral basis of the physician–patient relationship is the obligation of the physician to attempt to benefit the patient. Actions that do not contribute to this end because the harms substantially outweigh the benefits are not morally required (28). To assert that physicians should not have the discretion to refrain from patient-requested treatments in which the harms outweigh the benefits is to deny the medical profession the authority to interpret and apply its own defining values embodied in the Hippocratic oath. Such a position denies the nephrologist the authority to refuse to agree to the insertion of TCC for long-term use in patients who, despite knowing its antecedent risks, choose to defer the creation of a feasible AV access and confounds the physician's moral imperative, making him or her instead complicit in the patient's self-destructive choice.

Furthermore, avoiding use of a TCC when a properly functioning AVF or AVG is feasible is a matter of maintaining professionalism, particularly physician integrity. Recent research indicates the extent to which physician integrity is being challenged. In one study of the public's views on medical care for trauma, the majority of respondents (72%) said that physicians should do what patients want even if the physicians do not think it is medically indicated (29). In a study of physicians’ attitudes toward professional norms and the extent to which their practices conform to these norms, 36% of physicians admitted they would agree to order an expensive imaging study requested by the patient even although they knew it was unnecessary (30). Years ago, health economist Lester Thurow wrote that reform of the increasingly expensive United States health care system would require that physicians learn to say “no” to avoid practicing “bad medicine” (31). He included in his definition of bad medicine treatments that hurt patients (long-term dialysis with a TCC has a greatly increased risk of harm) and treatments whose costs are not justified by the benefits gained, as is true for TCCs. He said physicians could determine that a treatment is bad medicine when there is medical evidence on the cost effectiveness of alternative medical techniques, as exists in abundance for TCCs. As such, when a properly functioning AVF or AVG is feasible, physicians have the prerogative to desist in allowing the use of TCCs as long-term vascular access. A nephrologist's refusal to allow long-term TCC use must necessarily be preceded by appropriate patient and family education about the benefits and burdens of AVFs, AVGs, and TCCs. In response to the request of a patient who has initiated dialysis with a TCC, “Can’t I just continue to dialyze through the catheter? It seems to be working fine,” the nephrologist has several options (see Figure 1). The case in Box 1 demonstrates how the application of the options presented in the figure can result in a patient who wants to use a TCC long-term agreeing to receive an AVF.

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Figure 1.

Nephrologists’ possible responses to a patient's request to use a tunneled cuffed catheter for long-term dialysis access. TCC, tunneled cuffed catheter; AVF, arteriovenous fistula.