Termination of dialysis and palliative nephrology

Background As a result of medical progress, in most patients the initiation of dialysis is continuously shifted to older stages of life, which is not beneficial for every patient.Objective Presentation of the epidemiology and problems of dialysis in severely ill or aged patients, legal foundations, decision aids and recommendations for action.Material and methodEvaluation of epidemiological studies, discussion on fundamental works, review articles and expert recommendations.Results The highest 1-year prevalence for dialysis patients in Germany is for patients 75-84 years old. The mortality is much higher in this group than in younger hemodialysis patients and also in comparison to people of the same age with healthy kidneys. The risk of mortality during dialysis is influenced by diverse factors, such as age, comorbidities, frailty and serum albumin concentration and can be predicted by using clinical scores. Patient autonomy has the highest priority. A dialysis that is not indicated can be rejected by physicians. The quality of life, which is the most important objecitve for patients, is not always improved by dialysis. Older patients with chronic kidney disease (CKD) and certain impairments in whom dialysis was not initiated, show nearly the same life expectation as dialysis patients of the same age. Termination or non-initiation of dialysis should be considered in specific patient populations and situations. The ensuing Palliative care should be incorporated into Advanced Care Planning.Conclusion For multimorbid or very old dialysis patients the focus of treatment should be the maintenance of the quality of life. Decisions for or against dialysis treatment should be made jointly with patients, their relatives and caregiving persons and optimally far-sighted. Palliative efforts in nephrology should be promoted.