Table 2.

Recommended approach to starting and discontinuing hemodialysis in the elderly

1. Assess the patient’s goals of care (8,73) and institute advance care planning (10).
2. Assess the patient’s risk profile and prognosis (10,24,41).
3. Evaluate the patient’s prognosis in the context of his/her goals of care.
4. Communicate individualized treatment options and likely outcomes (best case/worst case) (10).
5. Engage the patient and family in deliberation on treatment choices (10,73).
6. Make individualized treatment recommendations to fit the patient’s goals of care if the patient prefers a physician-led decision-making process or if patients or surrogate decision struggle with their choices.
7. Consider recommending against dialysis in patients with very poor prognosis, contraindications, or safety concerns (10).
8. Consider a time-limited trial with predefined milestone measures of success/failure if there is significant ambivalence or lack of consensus. Involve the ethics consult team or use other due process in challenging cases (10).
9. Identify and treat burdensome symptoms and minimize treatment burden (75). Involve specialist palliative care physicians for complex cases (10).
10. Periodically reassess the patient’s willingness to continue dialysis as well as hospice eligibility.
11. Enable the patient to opt out of dialysis if continuation is no longer consistent with his/her goals of care.