Informing our elders about dialysis: is an age-attuned approach warranted?

As the fastest growing sector of the incident ESRD population, older patients constitute a group for which renal replacement therapy has special implications. Older CKD patients have unique needs by virtue of advanced age, high prevalence of comorbid conditions, slower progression of renal disease, and reduced survival. Burdens and risks attendant to dialysis may be amplified in the older patient and patients with impaired functional status or comorbid conditions, and therefore, dialysis may confer little to no survival benefit. Rates of dialysis withdrawal are highest among the oldest patients, raising the possibility that the standard content of informed consent for dialysis warrants an age-sensitive approach that is attuned to the very different balance of pros and cons of dialysis for older patients with multiple comorbidities and younger patients with limited comorbidity. Informed consent for older patients should include presentation of risks, benefits, and burdens associated with dialysis, age-specific estimates of prognosis with and without dialysis, and potential for loss of independence and decline in functional status with initiation of dialysis. In this article, medical evidence and clinical practice guidelines relevant to advance care planning for the older patient with CKD are reviewed, issues to consider in the dialogue with older patients contemplating dialysis are presented, and recommendations for an age-attuned approach to informed consent for older CKD patients are made.