Ethical and legal obligation to avoid long-term tunneled catheter access.

Despite recent national initiatives promoting the arteriovenous fistula as the initial, primary, and sole vascular access to be used by hemodialysis patients and recommending a decrease in the prevalence of tunneled cuffed catheters to less than 10%, the prevalence of tunneled cuffed catheters as hemodialysis access is increasing. This study describes the risks of tunneled cuffed catheters, explores the reasons why they remain prevalent, and presents the stance that nephrologists have an obligation to offer tunneled cuffed catheters only for temporary use and not as an acceptable alternative for long-term vascular access to patients for whom a properly functioning arteriovenous fistula or graft is possible. Recommendations for tunneled cuffed catheter use were based on dialysis clinical practice guidelines and the medical evidence regarding outcomes of use of arteriovenous fistulas and tunneled cuffed catheters. The authors found that compared with dialysis with arteriovenous fistulas, long-term dialysis with tunneled cuffed catheters is associated with (1) two to threefold increased risk of death, (2) a five to 10-fold increased risk of serious infection, (3) increased hospitalization, (4) a decreased likelihood of adequate dialysis, and (5) an increased number of vascular access procedures. To adequately inform patients about access options, nephrologists are ethically obligated to systematically explain to patients the harms of tunneled cuffed catheters. If catheters must be used to initiate dialysis, nephrologists should present catheters only as "temporary" measures and "unsafe for long-term use."

[Patient's consent to central venous catheterization]. / Consenso informato al posizionamento dei cateteri venosi centrali: una proposta operativa.

The need to obtain a patient's consent for his health care is a principle set out in the Italian Constitution, which safeguards a person's right to health. Articles 13 and 32.2 confirm a person's freedom and the right to make free decisions about one's medical treatment. Nobody must be obliged to any medical procedure, unless as by law enacted. The obligation to inform patients is important during the contractual phase: consent is an essential element in the professional contract governing the relationship between a physician and a patient. The former is obligated to inform the latter about his medical intervention clearly and precisely, to enable the patient to decide freely whether to undergo a medical procedure. At this point, it is also essential to obtain a patient's consent for those treatments that although they are carried out in a correct and careful way, could damage a person's physical integrity. The failure to obtain consent could give rise to a burden of responsibility on behalf of the clinician. A central venous catheterization in hemodialysis (HD) is a common procedure performed during routine nephrological treatments. Our signed informed consent form prior to introducing a central venous catheter is thought to satisfy requirements provided for in current regulations to give correct information.