QW25-February 2025

Question 1: Select each option to validate with explanations

An 82-year-old woman with advanced heart failure, chronic kidney disease stage 4 (baseline creatinine 2.8 mg/dL), and metastatic lung cancer with extensive bony metastases is admitted to the ICU with septic shock due to a urinary tract infection. Despite receiving broad-spectrum antibiotics, IV fluids, and norepinephrine for persistent hypotension, she has been anuric for 24 hours, and her creatinine has risen to 5.8 mg/dL. Her trachea is intubated and she is sedated with propofol and remifentanil infusions, her Sequential Organ Failure Assessment (SOFA) score is 16. Her prior medical records indicate that during a previous hospitalization, she expressed a wish to "focus on comfort and avoid unnecessary interventions," but no formal advance directive or do-not-resuscitate (DNR) order was completed.
Her daughter insists on starting renal replacement therapy (RRT), stating, “We have to do everything possible,” while her son is concerned about prolonging her suffering. The ICU team is divided: one physician suggests a time-limited trial (TLT) of RRT, while another believes it would be futile given her poor prognosis. The patient’s nurse raises concerns about the burdens of aggressive care in this scenario.

Question: Which of the following is the most appropriate next step in managing this complex situation?

A. Start continuous renal replacement therapy (CRRT) with a time-limited trial (TLT) of 72 hours to assess response while addressing family concerns.

B. Engage in a structured goals-of-care discussion with the family, emphasizing the patient’s prior wishes, prognosis, and the limited benefit of RRT in this scenario.

C. Proceed with RRT as requested by the daughter, as the absence of a formal advance directive obligates the medical team to honour family decisions.

D. Avoid RRT and initiate palliative care measures, as the patient's high SOFA score and multiorgan failure indicate a non-survivable illness.

E. Refer the case to the hospital ethics committee to resolve the conflict between the healthcare team and the family.

Wrong Answer:Option A (Start CRRT immediately) Initiating an RRT without considering the specific prognosis of the patient, as well as their clearly expressed wishes and values, is deemed inappropriate. This practice often fails to improve outcomes for individuals in the terminal stages of their illness. Furthermore, it may inadvertently increase their suffering and distress, raising ethical concerns regarding the quality of care. It is essential to take into account the patient's circumstances and desires when making such critical decisions, rather than adhering to a standardized protocol that may not serve their best interests.

Right Answer:B. Engage in a structured goals-of-care discussion with the family, emphasizing the patient’s prior wishes, prognosis, and the limited benefit of RRT in this scenario.

Explaination:
Engage in a structured goals-of-care discussion with the family, emphasizing the patient’s prior wishes, prognosis, and the limited benefit of RRT in this scenario.

Clinical Pearls: The decision to initiate renal replacement therapy (RRT) in patients nearing the end of life involves a delicate balance of medical and ethical considerations. Here are a few important points to keep in mind:
1. Values and Preferences: Understanding the patient's values, beliefs, and goals for their care is crucial. Some patients might prioritize quality of life and comfort over aggressive treatments, while others may want to pursue all possible options to extend life.
2. Prognosis: The patient's overall prognosis and life expectancy are important factors. RRT might not significantly improve outcomes in patients with limited life expectancy or those with multiple comorbid conditions.
3. Quality of Life: The potential benefits of RRT should be weighed against the burdens and impact on the patient's quality of life. This includes considering the physical, emotional, and social aspects of living with RRT.
4. Goals-of-Care Discussion: Engaging in a thorough goals-of-care discussion is essential. This should involve the patient (if possible), their family, and the healthcare team to ensure everyone understands the potential benefits, risks, and alternatives to RRT.
5. Informed Decision-Making: Providing clear and honest information about the prognosis and treatment options helps patients and families make informed decisions that align with their values and preferences.
6. Emotional Support: Offering emotional and psychological support to patients and families during these discussions is vital. This can help them cope with the stress and uncertainty of making such challenging decisions.

Wrong Answer:• Option C (Proceed with RRT based on family wishes) While family input is important, their decision should align with the patient’s previously stated goals. Initiating RRT solely based on family insistence, without factoring in the patient’s wishes, may lead to non-beneficial care.

Wrong Answer:Option D( Avoid RRT altogether) Labeling renal replacement therapy as futile, especially when there has not been a clear and thorough discussion regarding its specific goals and the potential for providing symptom relief, may significantly obstruct the process of shared decision-making. This lack of dialogue can prevent patients and healthcare providers from engaging in meaningful conversations about treatment options and the implications of those options on the patient’s quality of life.

Wrong Answer:Option E (Initiate RRT with TLT): A time-limited trial (TLT) can be a valuable tool when there is uncertainty about the benefits of RRT. However, in this case, the patient's prior expressed wishes to avoid prolonged suffering indicate that the decision to start RRT should only follow a clear discussion of goals of care.

Reference:

1. Quinlan SC, Murphy N, Braham P, et al. Critical care nephrology and palliative care in the ICU: Integration and engagement. Clin J Am Soc Nephrol. 2020;15(10):1455-1464.
2. Okon TR, Vats HS, Dart RA. Palliative medicine referral in patients undergoing continuous renal replacement therapy for acute kidney injury. Renal failure. 2011 Aug 1;33(7):707-17.
3. An JN, Kim SG, Song YR. When and why to start continuous renal replacement therapy in critically ill patients with acute kidney injury. Kidney Research and Clinical Practice. 2021 Dec;40(4):566.
4. Moss, Alvin H., and others (eds), Palliative Care in Nephrology, Integrating Palliative Care (New York, 2020; online edn, Oxford Academic, 1 July 2020), https://doi.org/10.1093/med/9780190945527.001.0001
5. Lanini I, Samoni S, Husain-Syed F, Fabbri S, Canzani F, Messeri A, Mediati RD, Ricci Z, Romagnoli S, Villa G. Palliative Care for Patients with Kidney Disease. J Clin Med. 2022 Jul 5;11(13):3923. doi: 10.3390/jcm11133923.
6. Sekar A. Time-limited trials of dialysis in the intensive care unit: Are we timing dialysis initiation appropriately. Urol Nephrol Open Access J.;20186(2):57-8.