Futility analysis of treatment prolongation in patients with end-stage chronic kidney disease from medical perception
DOI:
https://doi.org/10.5281/zenodo.10127871Keywords:
medical futility, professional autonomy, personal autonomy, clinical decision making, principled ethicsAbstract
Introduction: chronic kidney disease is a pathology that reduces the expectancy and quality of life of patients. Doctors are primarily responsible for preserving the patient's life and are responsible for shared decision making. Objective: to analyze the perception of medical personnel regarding the prolongation of renal replacement treatment in patients with chronic kidney disease in the terminal phase in the dialysis unit at the General Teaching Hospital of Ambato, Ecuador. Method: a qualitative research was carried out, with a semi-structured interview that consisted of questions guided by the theory-hypothesis of the topic. The study sample was made up of doctors from the Dialysis Unit, responsible for the clinical management of patients with chronic kidney disease undergoing dialysis treatment. The protocol was approved by the Human Research Ethics Committee of the Pontificia Universidad Católica del Ecuador, with approval code CEI-88-2020. Results: the thematic analysis showed that doctors need to comprehensively ethically and clinically evaluate the patient before maintaining or terminating hemodialysis; The level of knowledge and ethical-clinical skills influence decision making. Furthermore, the application of Beauchamp and Childress' bioethical principles to decision making is vague, morbidly confusing, and therefore irrelevant to this type of decision. Conclusions: doctors perceive the need to comprehensively evaluate the patient, taking into account not only the physical but also the psychological, social and economic condition of the patient. They consider it unnecessary to maintain hemodialysis treatment in a patient with a deteriorated quality of life, with reduced autonomy and whose prolonged treatment could cause more pain than benefit.
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References
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30. Rinehart A. Beyond the futility argument: The fair process approach and time-limited trials for managing dialysis conflict. Clin J Amer Soc Nephrol. 2013 Nov; 8(11):2000-6. DOI: https://doi.org/10.2215/cjn.12191212
31. Moss AH. Ethical principles and processes guiding dialysis decision-making. Clin J Am Soc Nephrol [Internet]. 2011 Sep 1 [citado 10 Feb 2023]; 6(9):2313-7. Disponible en: https://pubmed.ncbi.nlm.nih.gov/21896833/
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33. Germain MJ, Davison SN, Moss AH. When enough is enough: The nephrologist’s responsibility in ordering dialysis treatments? Am J Kidney Dis. 2011 Jul; 58(1):135-43. DOI: https://doi.org/10.1053/j.ajkd.2011.03.019
34. Manavalan M, Majumdar A, Harichandra Kumar KT, Priyamvada PS. Assessment of health-related quality of life and its determinants in patients with chronic kidney disease. Indian J Nephrol [Internet]. 2017 Jan [citado 4 Aug 2023]; 27(1):37-43. DOI: https://doi.org/10.4103/0971-4065.179205
35. Moss AH. Revised dialysis clinical practice guideline promotes more informed decision-making. Vol. 5, Clinical Journal of the American Society of Nephrology. 2010. p. 2380–3.
36. Berlinger N, Bruce Jennings N, Wolf SM. Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life. Second. New York: Oxford University Press; 2013.
2. Gómez Carracedo A, Arias Muñana E, Jiménez Rojas C. Insuficiencia renal. Sem Méd. 1947; 54(Pt 2 49):940.
3. MSP. Salud renal. Ecuador: Ministerio de Salud Púbica; 2015.
4. Bellver Capella V. Ética y políticas ante la investigación. Cuad Bioét. 2014; XXV:3:493–506.
5. Gracia D. Como Arqueros al blanco. 1ed. Bogotá, Colombia: Editorial El Búho Ltda.; 2004.
6. Paredes Escobar MC. Limitación del esfuerzo terapéutico en la práctica clínica. percepciones de profesionales médicos y de enfermería de unidades de pacientes críticos de un hospital público de adultos en la región metropolitana. Acta Bioet. 2012; 18(2):163-71. DOI: http://dx.doi.org/10.4067/S1726-569X2012000200004
7. Dugdale DC, Zieve D. Decidir respecto a tratamientos que prolongan la vida. MedlinePlus Enciclopedia Méd [Internet]. 2020 [citado 6 Sep 2023]. Disponible en: https://medlineplus.gov/spanish/ency/patientinstructions/000468.htm
8. Brody H. Futility: Definition and goals. Perspect Biol Med [Internet]. 2018 Jun. [citado 6 Sep 2023]; 60(3):328-30. Disponible en: https://muse.jhu.edu/article/684810
9. Sánchez González MÁ. Bioética en Ciencias de la Salud. Barcelona, España: Elsevier Masson; 2013.
10. Miller-Smith L. The true abuse of futility. Perspect Biol Med [Internet]. 2018 Jun [citado 6 Sep 2023]; 60(3):403-7. Disponible en: https://pubmed.ncbi.nlm.nih.gov/29375071/
11. Beca JP. La toma de decisiones en ética clínica. En: Seminario de Ética Clínica, 28 de septiembre de 2011; Centro de Bioetica; 2011. Disponible en: https://medicina.udd.cl/centro-bioetica/files/2014/05/La-Toma-de-decisiones-en-ética-clínica.pdf
12. Torralba Madrid MJ, Pérez Gásquez IM. La calidad de vida del paciente nefrológico desde la perspectiva bioética. Enfermería Global [Internet]. 2011 [citado 3 Sep 2023]; (24):210-7. Disponible en: https://revistas.um.es/eglobal/article/view/137461/124781
13. Schneiderman LJ, Ridder M de. Medical futility. In: Handbook of Clinical Neurology. Elsevier B.V.; 2013. p. 167-79.
14. García-Altés A, Peiró M, Artells JJ. Prioritising measures for consolidating shared decision-making in the services rendered by the Spanish National Health System. Gac Sanit. 2019 Sep; 33(5):408–14. DOI: https://dx.doi.org/10.1016/j.gaceta.2018.04.017
15. Légaré F, Adekpedjou R, Stacey D, Turcotte S, Kryworuchko J, Graham ID, et al. Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database Syst Rev [Internet]. 2018 Jul 19 [citado 30 Oct 2023]; 7(7):CD006732. DOI: http://doi.wiley.com/10.1002/14651858.CD006732.pub4
16. Kyriakopoulos P, Fedyk M, Shamy M. Translating futility. CMAJ [Internet]. 2017 Jun 12 [citado 25 Oct 2023]; 189(23):E805–6. DOI: https://doi.org/10.1503/cmaj.161354
17. Morata L. An evolutionary concept analysis of futility in health care. Journal of Advanced Nursing [Internet]. 2018 Jun [citado 27 Sep 2023]; 74(6):1289-300. Disponible en: https://pubmed.ncbi.nlm.nih.gov/29350780/
18. White B, Willmott L, Close E, Shepherd N, Gallois C, Parker MH, et al. What does “futility” mean? An empirical study of doctors’ perceptions. Medical Journal of Australia [Internet]. 2016 May [citado 30 Oct 2023]; 204(8):318.e1-318.e5. Disponible en: https://pubmed.ncbi.nlm.nih.gov/27125807/
19. Close E, White BP, Willmott L, Gallois C, Parker M, Graves N, et al. Doctors’ perceptions of how resource limitations relate to futility in end-of-life decision making: A qualitative analysis. J Medl Ethics [Internet]. 2019 Jun [citado 8 Feb 2023]; 45(6):373-9. Disponible en: https://pubmed.ncbi.nlm.nih.gov/31092631/
20. Maddocks I. Futility and utility. Med J Aust [Internet]. 2016 [citado 6 Sep 2023]; 204: 289-289.e1. Disponible en: https://pubmed.ncbi.nlm.nih.gov/27125793/
21. Motta de Morais I, Nunes R, Cavalcanti T, Silva Soares AK, Gouveia V. Percepciones de estudiantes y médicos sobre la “muerte digna.” Rev Bioét [Internet]. 2016 [citado 14 Mar 2023]; 24(1):108-17. Disponible en: https://www.redalyc.org/pdf/3615/361544715013_1.pdf
22. Bello SS, Vergara VP, O’Ryan SL, Alfaro BAM, Espinosa SA. Estudio de las percepciones y actitudes del personal de una unidad hospitalaria frente a enfermos terminales. Rev Chil Enf Resp. 2009; 25(2):91-8. DOI: http://dx.doi.org/10.4067/S0717-73482009000200005
23. Cifrese L, Rincon F. Futility and Patients Who Insist on Medically Ineffective Therapy. Sem Neurol [Internet]. 2018 [citado 8 Feb 2023]; 38(5):561-8. Disponible en: https://pubmed.ncbi.nlm.nih.gov/30321895/
24. Rivas García F. Vista de Envejecimiento y aspectos bioéticos de la ventilación mecánica en la enfermedad terminal. Rev Iberoam Bioét [Internet]. 2020 [citado 16 Mar 2023]; 12:1-12. Disponible en: https://revistas.comillas.edu/index.php/bioetica-revista-iberoamericana/article/view/11772/11411
25. Araujo-Cuauro JC. El debate entre la futilidad médica y la limitación del esfuerzo terapéutico. Desde una perspectiva bioética y legal. Rev Academia. 2017; 16(37):97-110. Disponible en: http://www.saber.ula.ve/handle/123456789/43324
26. Ruz H. Obstinación terapéutica y su límite con la ética: ¿cuándo detenerse? Rev Chil Anest. 2021; 50:252-68. DOI: https://doi.org/10.25237/revchilanestv50n01-15
27. Vukusich A, Catoni MI, Salas SP, Valdivieso A, Browne F, Roessler E. Problemas ético-clínicos en hemodiálisis crónica: Percepción de médicos y enfermeras. Rev Méd Chile [Internet]. 2016 [citado 7 Feb 2023]; 144(1):14-21. Disponible en: https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000100003&lng=es&nrm=iso&tlng=en
28. Ocharan-Corcuera J. Cuidados paliativos en la enfermedad renal crónica [Internet]. Vol. 112, Gac Méd Bilbao. 2015 Oct [citado 8 Feb 2023]. Disponible en: www.elsevier.es/dial
29. Svantesson M, Anderzén-Carlsson A, Thorsén H, Kallenberg K, Ahlström G. Interprofessional ethics rounds concerning dialysis patients: Staff’s ethical reflections before and after rounds. J Med Ethics [Internet]. 2008 May [citado 10 Feb 2021]; 34(5):407-13. Disponible en: https://pubmed.ncbi.nlm.nih.gov/18448727/
30. Rinehart A. Beyond the futility argument: The fair process approach and time-limited trials for managing dialysis conflict. Clin J Amer Soc Nephrol. 2013 Nov; 8(11):2000-6. DOI: https://doi.org/10.2215/cjn.12191212
31. Moss AH. Ethical principles and processes guiding dialysis decision-making. Clin J Am Soc Nephrol [Internet]. 2011 Sep 1 [citado 10 Feb 2023]; 6(9):2313-7. Disponible en: https://pubmed.ncbi.nlm.nih.gov/21896833/
32. Pimienta K. Planificación anticipada de las decisiones en pacientes con dependencia funcional severa desde la atención primaria en salud [Tesis de Maestría]. Bogotá: Universidad El Bosque; 2019 [citado 16 Mar 2023]. Disponible en: https://repositorio.unbosque.edu.co/handle/20.500.12495/1758
33. Germain MJ, Davison SN, Moss AH. When enough is enough: The nephrologist’s responsibility in ordering dialysis treatments? Am J Kidney Dis. 2011 Jul; 58(1):135-43. DOI: https://doi.org/10.1053/j.ajkd.2011.03.019
34. Manavalan M, Majumdar A, Harichandra Kumar KT, Priyamvada PS. Assessment of health-related quality of life and its determinants in patients with chronic kidney disease. Indian J Nephrol [Internet]. 2017 Jan [citado 4 Aug 2023]; 27(1):37-43. DOI: https://doi.org/10.4103/0971-4065.179205
35. Moss AH. Revised dialysis clinical practice guideline promotes more informed decision-making. Vol. 5, Clinical Journal of the American Society of Nephrology. 2010. p. 2380–3.
36. Berlinger N, Bruce Jennings N, Wolf SM. Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life. Second. New York: Oxford University Press; 2013.
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Published
2023-11-15
How to Cite
1.
Suaste-Pazmiño DI, Sánchez-del Hierro GA, País-Cadeno PC. Futility analysis of treatment prolongation in patients with end-stage chronic kidney disease from medical perception. Rev Inf Cient [Internet]. 2023 Nov. 15 [cited 2025 Apr. 2];102:4311. Available from: https://revinfcientifica.sld.cu/index.php/ric/article/view/4311
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