Ethical Considerations in Acute Renal Replacement Therapy

Morality of Renal Replacement

The ethical management of intensive care support procedures can be difficult. A basic question refers to the question of whether RRT is moral. If it is, where does its morality stand? The answers can come only from our view of health and healthcare. Health could be considered just a physical accident (such as beauty, height, or the color of the eyes) and healthcare a commercial commodity reserved to those who can pay for it. If this were true, perhaps RRT (and, indeed, any other medical activity) would be only a technical act, one that must be managed with attention, commitment, and honesty but does not have any relevant intrinsic moral content.

On the contrary, health can be regarded as a fundamental good of every human being and healthcare as a basic human right. In this sense, RRT is more than a mere technical act and has some moral content. However, what is its specific aim?

RRT, as any other medical intervention, is a means, not a goal. Many people (including clinicians) believe that the aim of medicine is to heal diseases and that hospitals are the places where diseases are fought. This means mistaking means for goals. In reality, the aim of medicine is to help people with health problems to conceive and accomplish their project of the best possible life. In case of a curable disease, trying to heal the disease is usually the best way to realize such an aim.

Unfortunately, not all diseases are curable. However, people always can be cared for, especially those in terminal conditions. For this reason, every possible intervention should undergo a twofold scrutiny to ascertain that it is clinically appropriate and ethically proportionate. A medical intervention is clinically appropriate when it will reasonably attain the beneficial clinical effect over that specific person's health problem. Assessing the clinical adequacy means determining the limit of the medical intervention to oppose a pathologic process and support the biologic frailty of the person for whom it is used. An evidence-based approach should be used to determine which possible action is the most adequate and to avoid useless or futile interventions. A medical intervention is ethically proportionate when its clinical adequacy is not only a biologic parameter but also a biographic one; it also can affect positively that person's life, helping to accomplish his or her life project. In this sense, the limit beyond which the medical intervention should be foregone is not that of the intervention to support the biologic frailty of the person, but rather the level of irretrievable frailty that the person sets as a limit for her life story.

In this sense, people with health problems deserve a twofold right: to be offered only clinically adequate interventions and to decide to what extent those clinically adequate interventions are meaningful for their life. The best decision can come only from a sharing of expertise :

Caring for a suffering person and doing the most possible to help that person recover are moral actions. A clinically sound, proportionate, and compassionately administered medical action (included RRT) should be considered a good and adequate approach until proven otherwise. The best proof is the patient's valid refusal of therapy.

Three factors—clinical indication, informed consent, and compassionate administration—are the basis of the ethical foundation of RRT.

Information and Consent for Renal Replacement Therapy

People with chronic renal failure necessitating long-term ambulatory RRT (dialysis) are usually able to be informed and to give valid consent or refusal. Actually, the refusal or discontinuation of dialysis is the cause of approximately 25% of deaths of patients in irreversible renal failure.

Such valid consent or refusal is not usually possible for the critically ill patient in an intensive care unit (ICU) who requires RRT as part of intensive support. The competence of these patients is typically inadequate at the time when important therapeutic decisions are made. Consequently, such patients may receive care they would not have chosen and whose aim is inconsistent with their wishes.

However, at least some patients are competent at the time of hospitalization or ICU admission. Whenever possible, their involvement in the decision-making process is mandatory. Every piece of information regarding a patient's health status is the private property of that individual patient. Healthcare workers (HCWs) have the right and duty to manage such data only to make sense of them and to give them back to the patient so that she or he can make the best choice. Once the patient has been informed adequately, it is possible to agree with her or him on the course of care that is most fitting. Obviously, the competent patient can change his or her position; in this sense, informed consent is a continuous process and not a single event.

Patients can be informed in different ways. In the process of advance care planning (ACP), the patient, after being informed of diagnosis and prognosis, agrees on a course of therapy. Advance directives (AD) also can be drawn up by healthy people before facing a major health concern. They can include a “living will” (an instruction directive in which the patient specifies the level of acceptable therapy) and/or a proxy directive (“durable power of attorney for healthcare,” in which the patient indicates the person who can make sound decisions in her or his place, should she or he become incompetent).

Unfortunately, information to the patient is often inadequate, and advance care planning and advance directives are rare in everyday clinical practice. Even worse, these directives have not proved able to affect significantly the course of care of critically ill patients, because they often are ignored by HCWs.

Healthcare Workers and the Relatives of the Incompetent Patient

HCWs alone are not likely to be the best decision makers for their incompetent patients, especially when end-of-life decisions have to be made. An extreme variability exists among doctors in defining a patient's prognosis and in decision making about foregoing life-sustaining therapies (including RRT) across different countries, in different ICUs in the same country, and even between providers within the same ICU.

If the patient's competence is inadequate and her or his wishes are not known, the patient's relatives should be included in the decision-making process. This does not mean that the relatives should decide the course of therapy, which is always a medical decision. The family members have no clinical competence. Neither have they, in many countries, any legal authority to make surrogate decisions on behalf of an adult incompetent person. Nonetheless, the family are the upholders of their loved one's life project: they may be a precious source of information about the patient's wishes, especially when future quality of life is considered. Relatives should be helped to clarify what the patient would consider as her or his own best interest. On the other hand, what the relatives say could be conditioned by their own experience, moral and religious beliefs, or external interests, as well as anxiety and depression. Relatives' and surrogates' decisions do not always reflect accurately the patient's wishes and preferences.

For these reasons, the family of an incompetent patient and the HCWs should work together, in a shared decision-making process, to determine what the patient would have chosen in that situation. This requires time, specific skills, and a great amount of attention and sensitivity. The implementation of an “intensive communication strategy” can reduce the “compassion fatigue” of carers who have to make difficult decisions regarding end-of-life issues. This strategy includes an unrestricted visiting policy (open ICU), training in end-of-life ethics, a staff psychologist available on demand for consultation, daily meetings with families, and periodic debriefing for HCWs. Successful and effective communication is extremely important, and its lack is the main cause of family dissatisfaction.

Guidelines and Moral Principles

Guidelines are very useful because they provide the clinical, moral, and legal background for decision making. However, they are not always sufficient. No guideline would be able to determine the best decision for every patient. Each situation is unique because patients, families, and relatives are always different, and so are the HCWs.

Therefore with adequate references from official guidelines, the solution to every individual situation is found best within that situation. Shared ethical principles derived from “common morality” (autonomy, beneficence/nonmaleficence, and justice) are the ones currently accepted in the Western world. They can guide reasoning and decision making according to the needs of the case. However, they must be actualized in each particular case. Ethical reasoning and ethical consultation do not aim at the ideal course of action but at the best possible course of action in that specific setting with the available resources.

The aim of decision making is promoting patients' dignity; the principles are the means to reach such a goal. In case of conflict among principles, the one that best promotes the patient's dignity in the specific situation must be privileged. Therefore the moral principles are not absolute and admit exceptions. Obviously, such exceptions always must be dealt with in the most careful way. Any exception to any moral principle must be accepted only exceptionally and only if it is indispensable to best promote the patient's dignity, which is the goal of care. In such decisions, those who decide which principle should be sacrificed must assume the burden of proof. In conclusion, moral principles are clear and valid in general terms, but their specification, application, and balancing depend on circumstances.

Again, an optimal decision can be obtained only with continuous, overt, and honest circular communication among everyone involved in the care of the patient to determine clear goals of treatment, verify which therapies actually satisfy those goals, and define subsequent adequate strategies.

Great attention has been paid in the last few years to the appropriate shared decision-making process, to reach the best decision for people with chronic renal failure necessitating RRT. However, the proposed approach can work as well in the acute kidney injury settings. In fact, it provides for full patient information about diagnosis, prognosis, and treatment options, and development of emphatic relationships aimed to a shared advanced care planning.

In some complex cases, a time-limited trial of dialysis can be taken into account to better define prognosis by the medical team and a shared decision by the patient or legal surrogate, also considering family involvement.

In Box 148.1 , part A, a protocol is proposed to guide the decisional process for the terminally ill incompetent patient.