4.2 Preparation for Renal Replacement Therapy (RRT)

4.2.2 Selection of Patients

The higher proportion of elderly patients, diabetics and those with other comorbid conditions on RRT has resulted primarily from the relaxation of previously rigid selection criteria, partly conditioned by increasing medical expertise in the adaptation of available therapeutic modalities, and partly by rising public expectations. These expectations have been fostered by a political climate promoting a more explicit approach to resource allocation. The success of RRT itself has contributed in that patients who were relatively young and fit on commencing treatment have survived into old age with its attendant comorbidities which include those occurring as a result of long term treatment itself.

The approach to patient selection for RRT needs to be flexible and individualised. Hard and fast rules are unhelpful. All patients with ESRF should be considered for treatment and an assessment made of the potential benefits for particular patients in their individual circumstances. It is important to acknowledge the difficulty in obtaining a credible presumption of the patient's subjective perception of his/her likely quality of life. While a 'trial of dialysis' is sometimes advocated, the point at which the trial is deemed to have failed can be difficult to acknowledge and is seldom the same for patient, family, nurse and physician. Withdrawal of treatment after such a trial may be more difficult to manage and at least as stressful for all concerned as withholding dialysis in the first place. In practice there are no objective criteria which can be applied to identify patients who are unsuitable for dialysis.

The working rule is that all patients who are deemed likely to benefit should be accepted for treatment. In a modern era this is seldom a decision which resides exclusively with the doctor. Multidisciplinary input and family involvement is imperative. Just as important is the respect for death with dignity in severely ill patients who should be spared intrusive and inappropriate therapies.