Decision-Making in Patients With Cancer and Kidney Disease Jennifer S. Schereremail, Mark A. Swidler Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY Department of Geriatrics and Palliative Medicine and Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY Renal Division, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY DOI: dx.doi.org/10.1053/j.ackd.2013.07.005 Abstract Full Text Images References Article Outline Approach to Decision-Making PS and Functional Assessment Prognostication: AKI/CKD in a Cancer Patient Prognostication: ESRD Patients With Cancer Communication of Prognosis Forgoing Dialysis: The Role of Palliative Care Including Hospice Choosing Treatment: Revisiting the Case Scenarios Conclusion Thoughtful decision-making in a patient with cancer and kidney disease requires a comprehensive discussion of prognosis and therapy options for both conditions framed by the individuals preferences and goals of care. An estimate of overall prognosis is generated that includes the patients clinical presentation and parameters associated with adverse outcomes, such as age, performance status, frailty, malnutrition, and comorbidities. Empathic communication of this information using a shared decision-making approach can lead to an informed decision that respects patient autonomy and is consistent with the patients “big-picture” goals and personal values. Key Words: Shared decision-making, Dialysis, Prognosis, Palliative care, Onconephrology + Clinical Summary The decision to initiate or forgo (withhold or withdraw) dialysis in a patient with cancer and kidney disease involves a methodical and individualized approach. Malignancy stage, cancer treatment options, response to therapy, quality-of-life (QOL) goals, performance status (PS), comorbidities, and geriatric syndromes must be integrated with traditional kidney criteria in the dialysis decision-making process. Most importantly, this patient will experience the cumulative effects of 2 serious illnesses. Hospitalized cancer patients with acute kidney injury (AKI) studied over a 3-month period had longer hospital stays (100%), higher costs (106%), and higher odds for death (adjusted [adj.] odds ratio [OR], 4.72; 95% confidence interval [CI], 3.30-6.75) compared with those without AKI.1 Malignancy is an independent predictor of death in dialysis patients (adj. OR 1.3; 95% CI 1.1-1.5)2 and is associated with an increased risk of cancer-specific mortality in CKD patients (adj. hazards ratio [HR] 1.20; 95% CI 1.02-1.42).3 Given these challenges, the risks and benefits of dialysis therapy (DT) must be considered in the context of overall prognosis and patient-specific goals. Integration of kidney and cancer disease trajectories, framed within the bioethical principles of autonomy, beneficence, nonmaleficence, and justice, is an essential part of the decision-making process. Dialysis is generally considered a routine procedure in patients who develop ESRD or AKI. However, there is growing evidence that for some patients, particularly the frail elderly and those with a significant number of comorbid conditions, dialysis is associated with more burdens than benefits.4 In selected patients, it may be appropriate to forgo DT and opt for nondialysis medical therapy (NDMT), defined as “an acceptable alternative [to dialysis] that may better achieve patients goals of care,” with hospice referral when prognosis is less than 6 months.5 The DT vs NDMT decision will be more commonly faced by the elderly, a group with a rising incidence of kidney disease and cancer.6, 7 The incident rate of ESRD in patients 75 years of age or older has grown 12.2% since 20006 whereas that of cancer in patients older than 65 years of age is nearly 10 times that of those younger than 65 years of age (2113.7 per 100,000 vs 224 per 100,000).7 In addition, functional decline and loss of independence are associated with dialysis initiation in elderly patients8, 9, 10 and would have implications for cancer treatment choices and QOL. A systematic approach to dialysis decision-making includes a comprehensive clinical assessment, knowledge of treatment choices, accurate prognostication, effective communication of that prognosis, and explanation of kidney treatment options guided by the patients preferences and goals of care. Table 1 describes common clinical scenarios of seriously ill cancer patients with kidney disease. In each scenario, the nephrologist should assess the potential consequences of dialysis on the patients short- and long-term survival, QOL, and symptom burden. This review provides a general guide for dialysis decision-making in the cancer patient. Table 1 Clinical Case Scenarios 1.Fifty-four-year-old father of 2 teenagers currently undergoing treatment for cancer develops AKI secondary to acute tubular necrosis and may imminently require dialysis. 2.Sixty-seven-year-old female with CKD stage 4 with a newly diagnosed monoclonal gammopathy and a preadmission KPS > 50 develops superimposed AKI secondary to “myeloma kidney”. The patients previously stated preferences were to continue to work and remain independent. 3.Eighty-six-year-old nursing home patient started on dialysis 6 mo ago, wheelchair-dependent for 2 mo, is admitted with pneumonia and found to have a new hematologic malignancy. 4.Eighty-year-old female with CKD stage 3 and metastatic breast cancer with no further treatment options develops AKI and uremic symptoms. 5.Seventy-year-old male dialysis patient with cancer undergoing chemotherapy treatment develops septic shock with multiorgan failure and is transferred to the ICU. After 2 wk of aggressive therapy, the patient remains dependent on a ventilator and is unable to be weaned. His living will states that he would not want to live on life support if there were no realistic chances of returning home. The family insists on continued aggressive medical care. Abbreviations: AKI, acute kidney injury; ICU, intensive care unit; KPS Karnofsky Performance Status. Approach to Decision-Making A suggested approach to decision-making is summarized in Table 2 and discussed below.5, 11 This method incorporates material from the Renal Physicians Association (RPA) Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis (2010), a set of 10 evidence-based recommendations that guide nephrologists through the dialysis decision-making process and provide indications for NDMT and palliative (supportive) care interventions.5 Table 2 Decision-Making Process in Cancer Patients With AKI, Advanced CKD/ESRD, or Receiving Dialysis 1.What are the ethical concerns? Assess the benefits and burdens of DT. •Will DT in a patient with cancer lead to an acceptable short- or long-term improvement in overall status or increase symptom burden and suffering to a level that compromises QOL and does not achieve the patients goals? 2.What are the values at stake for the patient? Explore the patients narrative and any associated cultural/ethic/religious influences. •What are the patients preferences? •What are the patients big-picture goals? •What does the patient define as QOL? 3.What are the clinically relevant facts? Provide patient-specific medical data and develop prognosis. •What are the patients PS and prognosis? •How will prognosis and PS be affected by the clinical interplay of cancer, kidney disease, other comorbidities, and DT? •Will DT improve PS so cancer treatments can be initiated or resumed? •Are there available cancer treatments? •Is the cancer refractory or metastatic? •Will DT be temporary or chronic? •What is the patients symptom burden and how will DT affect it? 4.What can the nephrologist do? Initiate or forgo DT. •Is a time-limited trial appropriate? •Is the patient a candidate for NDMT? •Include palliative care support. •Discuss hospice referral if prognosis is
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