Opting out of dialysis ­ Exploring patients' decisions to forego dialysis in favour of conservative non-dialytic management for end-stage renal disease.

BACKGROUND: Dialysis prolongs the life of people with end-stage renal disease (ESRD), but for patients who are elderly and suffer multiple comorbid illnesses the benefits of dialysis may be outweighed by its negative consequences. Non-dialytic conservative management has therefore become an alternative treatment route, yet little is known on patients' experience with choosing end-of-life treatment. AIMS: To gain insight into the decision-making process leading to opting out of dialysis and the experience with conservative non-dialytic management from the patients' perspective. DESIGN: Qualitative study using semi-structured interviews. Interpretative phenomenological analysis was undertaken as the framework for data analysis. SETTING/PARTICIPANTS: N = 9 ESRD participants who have taken the decision to forego dialysis were recruited from the advanced care programme under the National Healthcare Group, Singapore. RESULTS: Participants discussed life since ESRD diagnosis, and the personal and contextual factors that led them to choose conservative management. The perceived physical and financial burden of dialysis both for the individual but most importantly for their family, uncertainty over likely gains over risks which were fuelled by communication of negative dialysis stories of others, coupled with sense of life completion and achievement led them to refuse dialysis. All participants took ownership of their decision despite contrary advice by doctors and were content with their decision and current management. CONCLUSIONS: Study highlights the factors driving patients' decisions for conservative non-dialytic management over dialysis to allow medical professionals to offer appropriate support to patients through their decision-making process and in caring them for the rest of their lives.

End-of-life care in the general wards of a Singaporean hospital: an Asian perspective.

BACKGROUND: Despite international differences in cultural perspectives on end-of-life issues, little is known of the care for the dying in the general wards of acute hospitals in Asia. METHODS: We performed a retrospective medical chart review of all 683 adult patients who died without intensive care unit (ICU) admission in our Singaporean hospital in 2007. We first evaluated the prevalence of do-not-resuscitate (DNR) orders and orders for or against life-sustaining therapies; second, if such orders were discussed with the patients and/or family members; and third, the actual treatments provided before death. RESULTS: There were DNR orders for 66.2% of patients and neither commitment for DNR nor cardiopulmonary resuscitation (CPR) for 28.1%. Orders to limit life-sustaining therapies, including ICU admission, intubation, and vasopressors/inotropes were infrequent. Only 6.2% of the alert and conversant patients with DNR orders were involved in discussions on these orders. In contrast, such discussions with their family members occurred 82.9% of the time. Interventions in the last 24 hours of life included CPR (9.4%), intubation (6.4%), vasopressors/inotropes (14.8%), tube feeding (24.7%), and antibiotics (44.9%). Analgesia was provided in 29.1% of patients. CONCLUSIONS: There was a lack of commitment by doctors on orders for DNR/CPR and to limit life-sustaining therapies, infrequent discussions with patients on end-of-life decisions, and excessive burdensome interventions with inadequate palliative care for the dying. These findings may reflect certain Asian cultural biases. More work is required to improve our quality of end-of-life care.