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Ethical Issues
Pages 51-61

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From page 51...
... Congress did not foresee a patient population whose average age would increase to 60 years, or one with substantial comorbid conditions other than renal disease. But it did not seek to constrain growth along these lines.
From page 52...
... The number of new patients has increased steadily, as has the median age of dialysis patients and the number of dialysis patients with a serious, chronic primary diagnosis such as diabetes (USRDS, 1990~. This change occurred in part because physicians, as they gained experience treating older patients and patients with greater medical complications, achieved successful outcomes.
From page 53...
... The question of the appropriateness of dialysis arises, then, for ESRD patients who have major comorbidities and a limited life expectancy. These include patients with serious comorbidities such as atherosclerotic, cardiac, and peripheral vascular disease, chronic pulmonary disease, cancer, or AIDS, and who are close to death and whose course cannot be interrupted by dialysis treatment.
From page 54...
... , when fully informed of the benefits and burdens of treatment, should evaluate the proposed treatment in terms of their personal values and accept or reject the physician's recommendation. Quality-of-life measures, developed as research tools for assessing populations and individual patients, including ESRD patients, have not been used for decision making about the initiation or termination of treatment.
From page 55...
... There should be a means for conflict resolution available to the health care team, the patient, and the family short of resorting to the court system. Hospital ethics committees serve this function, as well as the usual range of other hospital purposes, and are available to hospital-based dialysis units (Foss and Cranford, 19851.
From page 56...
... Prior to the initiation of the trial, there should be carefully delineated parameters of what outcomes of dialysis therapy justify continuation so that at the conclusion of the trial, a decision regarding further dialysis can be made. Advance Directives At some point, dialysis patients may become incompetent as a consequence of kidney failure or dialysis treatment.
From page 57...
... In all cases, the physician's responsibility is to care for the patient with an understanding of human frailty and the complex psychology of living with chronic illness, to make efforts to develop effective communication, and to ensure continuity of care. Legal contracts between patients and health professionals may be necessary in some cases to specify mutual rights and responsibilities.
From page 58...
... Although the complexity and frailty of human existence must be acknowledged, and physicians cannot insist that patients adhere to strict rules in order to be eligible for care, a different consideration occurs in the case of a transplant patient than for a dialysis patient. Transplanted kidneys have to be viewed as absolutely scarce resources for which there is a substantial waiting list.
From page 59...
... and hospice programs are required to establish and maintain written policies regarding advance directives for all adult individuals receiving medical care from such organizations; to provide written information to each such individual regarding their rights to accept or refuse treatment and to formulate advance directives; to document in the individual's medical record whether or not an advance directive has been executed; and "not to condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive." Outpatient dialysis units were not specifically included among the organizations to which this legislation pertains, an apparent legislative oversight. Nevertheless, the legislation
From page 60...
... 1989. Social, ethical and legal issues involved in chronic maintenance dialysis.
From page 61...
... 1991. Origins of the Medicare kidney disease entitlement: The Social Security Amendments of 1972.


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