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Dialysis in the Frail Elderly — A Current Ethical Problem, an Impending Ethical Crisis

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ABSTRACT

The current practice of hemodialysis for the frail elderly frequently ignores core bioethical principles. Lack of transparency and shared decision making coupled with financial incentives to treat have resulted in problems of overtreatment near the end of life. Imminent changes in reimbursement for hemodialysis will reverse the financial incentives to favor not treating high-risk patients. In this article, we describe what is empirically known about the approach to hemodialysis today, and how it violates four core ethical principles. We then discuss how the new financial system turns physician and organizational incentives upside down in ways that may exacerbate the ethical dilemmas, but in the opposite direction.

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Acknowledgements

Contributors

We thank Mildred Z. Solomon, EdD, for her expert guidance and Amy J. Markowitz, JD, and the participants in her workshop at Mayo Clinic on April 13, 2012, for their valuable input and advice. We also thank Gladys Hebl for her help in preparing the manuscript for submission.

Funders

Dr. Keith Swetz received support for this research from the Mayo Foundation Department of Medicine Early Career Development Award.

Dr. Jon Tilburt received support from the following: Greenwall Foundation Faculty Scholars Program, Mayo Clinic Foundation Early Career Development Award, Center for the Science of Health Care Delivery at Mayo Clinic, Mayo Clinic Center for Translational Sciences Activities (CTSA), Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS) and Mayo Clinic Program in Professionalism and Ethics.

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None.

Conflict of Interest

The authors declare that they do not have any conflicts of interest.

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Authors and Affiliations

  1. Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA

    Bjorg Thorsteinsdottir MD

  2. Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA

    Keith M. Swetz MD, MA & Jon C. Tilburt MD, MPH

  3. Program in Professionalism and Ethics, Mayo Clinic, Rochester, MN, USA

    Keith M. Swetz MD, MA & Jon C. Tilburt MD, MPH

  4. Biomedical Ethics Research Unit, Mayo Clinic, Rochester, MN, 55905, USA

    Jon C. Tilburt MD, MPH

  5. Knowledge Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA

    Jon C. Tilburt MD, MPH

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  1. Bjorg Thorsteinsdottir MD
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Correspondence to Bjorg Thorsteinsdottir MD.

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Thorsteinsdottir, B., Swetz, K.M. & Tilburt, J.C. Dialysis in the Frail Elderly — A Current Ethical Problem, an Impending Ethical Crisis. J GEN INTERN MED 28, 1511–1516 (2013). https://doi.org/10.1007/s11606-013-2494-1

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