R BRENNAN1, H GOCK1
1St Vincent’s Hospital Melbourne, , Australia
Background: The moral distress of determining dialysis a futile treatment option in those it will physiologically benefit is an increasing predicament Nephrologists face. Additional complexities such as young age and fluctuating capacity heightens the magnitude of the dilemma. We report learnings from a recent case at our centre.
Case Report: A 39-year-old Indigenous Australian male with a history of mental illness, substance use, and incarceration was transferred to our hospital. He was symptomatic with a serum creatinine of 1200 and haemoglobin of 70 from end-stage renal failure, and required emergency haemodialysis (HD). Further management was complicated by the patient threatening staff, refusing dialysis, removing his permacath and absconding. There was uncertainty around the impact of uraemia and mental illness on his cognition, and medical and psychiatric teams varied in their assessments of capacity. Strained relationships with family resulted in no one willing to make decisions on his behalf. A public guardian was appointed and a multidisciplinary meeting (MDM) convened. Consensus opinion was that to adequately evaluate the viability of long-term dialysis, the patient needed to be assessed in a better physical and mental state. Permission was granted by the guardian for two weeks of treatment. After this time, there was unanimous agreement that dialysis was futile. He was subsequently provided palliative care.
Conclusions: There is no legal obligation to offer dialysis, however determining futility requires careful navigation of cultural, ethical and legal boundaries. This case provided several learning points including the complexity of assessing capacity, the significance of knowing a patient’s preferences, the merit in utilising an MDM approach, and the fact that despite a treatment being physiologically beneficial, it may still not be appropriate.
Rachel Brennan is a first year Nephrology Advanced Trainee at St Vincent’s Hospital in Melbourne. She is currently completing dual training in Nephrology and General Medicine, and has a special interest in chronic kidney disease and peri-operative medicine.