Aaron Wightman1. 1. Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, 98105, USA. Aaron.wightman@seattlechildrens.org.
Abstract
BACKGROUND: Time-limited trials of dialysis have been proposed as a third option in addition to initiation of treatment and comfort-care only in the setting of high uncertainty or discordance between the treating team and child/family or among the treating team. CASE-DIAGNOSIS/TREATMENT: The index case was noted antenatally to have severe kidney disease and pulmonary hypoplasia. In light of the guarded, but uncertain prognosis and a lack of consensus among the treating team, as well as between the treating team and the family, a time-limited trial of dialysis was initiated. Six days later the child developed bacteremia due to infection of the dialysis catheter. The treating team felt this was a failure of the trial and that future dialysis should be withheld, the family disagreed. CONCLUSION: A time-limited trial is a problematic option. Providers may be better suited by returning to the dichotomous choice of withholding or initiating treatment. KEY MANAGEMENT POINTS: • Time-limited trials offer potential benefits in terms of alleviating the burden of decision-making in the setting of uncertainty, offering an opportunity to forecast a poor prognosis, help avoid interprofessional conflict, and providing support for patients, their families, and staff. • Time-limited trials have important limitations, including the use of time limits, difficulty in determining clear, meaningful endpoints, and different interpretations of a trial of therapy between parents and providers. • Decisions regarding the initiation, withholding, and withdrawal of dialysis should be made based on regular assessments of the benefits and burdens of the intervention for the child. • Pediatric nephrologists are better served to abandon the concept of time-limited trials.
BACKGROUND: Time-limited trials of dialysis have been proposed as a third option in addition to initiation of treatment and comfort-care only in the setting of high uncertainty or discordance between the treating team and child/family or among the treating team. CASE-DIAGNOSIS/TREATMENT: The index case was noted antenatally to have severe kidney disease and pulmonary hypoplasia. In light of the guarded, but uncertain prognosis and a lack of consensus among the treating team, as well as between the treating team and the family, a time-limited trial of dialysis was initiated. Six days later the child developed bacteremia due to infection of the dialysis catheter. The treating team felt this was a failure of the trial and that future dialysis should be withheld, the family disagreed. CONCLUSION: A time-limited trial is a problematic option. Providers may be better suited by returning to the dichotomous choice of withholding or initiating treatment. KEY MANAGEMENT POINTS: • Time-limited trials offer potential benefits in terms of alleviating the burden of decision-making in the setting of uncertainty, offering an opportunity to forecast a poor prognosis, help avoid interprofessional conflict, and providing support for patients, their families, and staff. • Time-limited trials have important limitations, including the use of time limits, difficulty in determining clear, meaningful endpoints, and different interpretations of a trial of therapy between parents and providers. • Decisions regarding the initiation, withholding, and withdrawal of dialysis should be made based on regular assessments of the benefits and burdens of the intervention for the child. • Pediatric nephrologists are better served to abandon the concept of time-limited trials.
Authors: Aleksandra M Zurowska; Michel Fischbach; Alan R Watson; Alberto Edefonti; Constantinos J Stefanidis Journal: Pediatr Nephrol Date: 2012-10-09 Impact factor: 3.714