A descriptive analysis of health care rationing: A focus on renal disease and the elderly

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Content A DESCRIPTIVE ANALYSIS OF
HEALTH CARE RATIONING: A
FOCUS ON RENAL DISEASE AND THE ELDERLY
by
Lori L. Rosenquist
A Thesis Presented to the
FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE IN GERONTOLOGY
December 198 8
Copyright 1988 Lori L. Rosenquist
UMI Number: EP58952
All rights reserved
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Oissertatbn F\ibi s h*ng
UMI EP58952
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.
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THESIS COmiTTEE
DEDICATION
To my parents, James and Joyce
For your unconditional love, support and
friendship which you so abundantly give
to your children and others.
11
Acknowledgements
Many individuals were involved throughout the
development and progress of this thesis to whom I am
sincerely grateful and wish to acknowledge for their
valuable contributions. The successful learning
experience which the process of producing this thesis
incorporated was due greatly to the roles played by
these key individuals.
Dr. Eileen Crimmins, as the chair of my thesis
committee, offered tremendous guidance and patience
throughout the preparation of this thesis. Her
suggestions, time and effort given were greatly
appreciated and valuable. Her support, encouragement,
and interest in my pursuit of this topic means a great
deal to me personally. Dr. Edward L. Schneider, as a
member of my thesis committee offered expertise and
suggestions which also further enhanced the quality of
this product. It has been an extreme pleasure and
privilege to work with these individuals throughout my
graduate studies at the Andrus Gerontology Center, and
to have the opportunity to work with them on this
thesis project has been an extremely rewarding
experience.
The following physicians in the field of kidney
iii
disease were instrumental in offering their noted
expertise and knowledge in discussing with me relevant
issues addressed in this thesis and various related
issues which they encounter within their
profession. These individuals include Dr. Neil Glass,
Texas Tech University Health Sciences Center, Lubbock,
Texas; Dr. Richard Glassock, Harbor-UCLA, Los Angeles,
CA; Dr. Thomas Peters, University of Tennessee for
the Health Sciences, Memphis, TN; and Dr. Robert
Schrier, University of Colorado Health Sciences
Center, Denver, CO. Their sincere dedication to the
field of medicine and to the lives of their kidney
patients warrants a great deal of respect and
admiration along with continued hope for the future of
renal disease patients. They provided valuable
knowledge and insight into many different areas of
this thesis and continued to spark further areas of
creativity and interest through our various
conversations. Their helpful and friendly
personalities are much appreciated, and I hold them
all in the highest regard. I would also like to thank
Suzanne Adams, Charles Plante and Dolph Chianchiano of
the National Kidney Foundation for their suggestions
and continued support.
I am fortunate to have a circle of friends which
have offered an incredible amount of support,
iv
encouragement and highly appreciated senses of humor
to the process of writing this thesis, always
reminding me that the goal of its completion was
attainable. My special friends, both staff and
residents, of Kingsley Manor for their never fading
smiles and uplifting words of encouragement. Dr.
James and Mrs. Betty Birren for allowing the solitude
of their lovely home in which a majority of this
thesis was written. Jeanne Miller, the Andrus
librarian, who helped me a great deal throughout the
process, not only in saving precious time but also
offering her expertise and assistance whenever
possible. In particular, my fellow students at the
Andrus Center for not only their friendship and
support, but knowing when a few encouraging words or
some laughter were the prescriptions needed to
continue working towards the completion of this
project.
Lastly, I would like to express my heartfelt
gratitude to my family for their continued faith in me
and encouragement throughout the process of this
thesis and my graduate studies. I'd like to offer a
special thanks to my parents for their assistance with
valuable information on kidney disease, and also for
their dedication as active volunteers in the National
Kidney Foundation. Their enthusiasm, humor, and
support continued to give me additional energy and
perseverance throughout this thesis project.
Lori L. Rosenquist
Hollywood, California
August 1988
VI
TABLE OF CONTENTS
Page Number
I - INTRODUCTION...............................1
II- RENAL DISEASE IN THE ELDERLY..............8
A. A BRIEF HISTORY - ETHICS AND
LEGISLATION
B- KIDNEY FUNCTION AND RENAL FAILURE
C. TREATMENT MODALITIES
1. KIDNEY DIALYSIS
a. HEMODIALYSIS
b. PERITONEAL DIALYSIS
2. KIDNEY TRANSPLANTATION
D. SURVIVAL RATES AND OUTCOMES OF ELDERLY WITH
RENAL DISEASE IN THE UNITED STATES
III- PATIENT POPULATION AND UTILIZATION...... 40
IV- TREATMENT COSTS AND LEGISLATIVE ISSUES
IN ESRD..............-....................44
V- PATIENT ADVOCACY-
THE NATIONAL KIDNEY FOUNDATION...........49
VI- HEALTH CARE RATIONING....................53
A- OVERVIEW OF RATIONING CONCEPTS
B. GREAT BRITAIN- THE NATIONAL HEALTH SERVICE
AND RENAL DISEASE TREATMENT FOR THE ELDERLY
1- U-S- AND BRITAIN- DIFFERING PHILOSOPHIES ON
ALLOCATION OF SERVICES FOR ELDERLY RENAL
DISEASE PATIENTS
C- A RECENT RATIONING PROPOSAL- BY DANIEL CALLAHAN
1- OVERVIEW OF CALLAHAN'S PROPOSAL
2- THE IMPACT ON ELDERLY RENAL DISEASE PATIENTS
3- DISCUSSION OF CALLAHAN'S PROPOSAL
VII- IMPLICATIONS/PROJECTIONS FOR THE FUTURE
IN RENAL DISEASE......................... 78
A- VIEWS FROM RENAL DISEASE EXPERTS
1- CASE STUDY
VIII- CONCLUSION...............................91
REFERENCES......................................95
TABLES.........................................101
V l l
List of Tables
Page Number
Table 1- Warning Signs of
Kidney Disease.................. 101
Table 2. Diagnostic Problems of
Renal Disease in the Aged....... 102
Table 3. Prevention of Acute
Renal Failure ..... 103
Table 4. Nondialytic Management of
Chronic Renal Failure. ..... 104
Table 5. Assessment Information to
Obtain From Transplantation
Candidate...... 105
Table 6. Classic Characteristics of
Rej action .....106
Table 7. Medicare Program Enrollment
by Age, 1979-1984...............107
Table 8. Value of Life at Various Ages... 108
Table 9. Classifications for Morally
Appropriate Care........ 109
Vlll
I. INTRODUCTION
The escalating cost of health care in the United
States is causing a multitude of proposed solutions in
attempts to ease the growth of the federal deficit.
The increase in our older population is a factor which
plays a significant role in the costs encountered by
our health care delivery system. It is especially i
I
important to note that the fastest growing segment of
our population is in fact those over age 85 and to
I
ascertain the potential impact they could have on our !
i
health care system in the future. |
I
A service provided by Medicare to the elderly I
I
involves various life-sustaining technologies. As |
I
defined in Medicare regulations. End Stage Renal |
Disease (ESRD) is the "stage of chronic renal
impairment that appears irreversible and permanent, i
and requires a regular course of dialysis or kidney
transplantation to maintain life" (Commerce '
I
Clearinghouse, 1986). The increasing costs encountered |
by Medicare have sparked major discussions on the
topic of allocating life-sustaining technologies to
the elderly segment of our population. These
discussions have resulted in a great deal of thought
and examination of our system of health care delivery
and the ethical beliefs of which it is based.
1
Although the past thirty years have demonstrated great
technological advances in many forms of life-
sustaining procedures, it remains an area which does
not receive a great deal of attention unless one is
personally or professionally involved. On occasion,
however, an unusual case or situation surfaces and
brings the issue to the attention of the general
public. These cases usually become visible in the
U.S. because of the uncertainty among the
professionals involved regarding the appropriate
procedure to implement.
The medical arena involving life-sustaining
technologies is broad, therefore this analysis will
concentrate on elderly individuals with renal disease
as an example. Consider the following scenario:
— An 87 year old man, in generally good
health, suffers kidney failure due to a severe
flu virus. Should he be put on kidney
dialysis or considered for a kidney
transplant?—
Questions such as this involve many issues which
must be considered when evaluating the treatment
options. When deliberating this question, whether by
a lay person or health care professional, a few items
to consider would include the patient's preexisting
medical condition, cost/benefit of treatments, life
style, or age. The use of age as a criterion when
determining allocation of treatment is the specific
2
issue upon which this thesis will focus. The purpose
of this thesis is to use descriptive analysis to gain
insight into various aspects of kidney disease related
to the elderly in order to adequately evaluate health
care rationing concepts and proposals which affect the
elderly renal disease population. The knowledge
obtained will allow a firm foundation on which to
negate proposals which wish to ration life sustaining
treatments (ie: dialysis and transplantation) to the
elderly.
In the past, the availability of various forms of
treatment to those renal disease patients in need was
limited due to the lack of equipment, resources and
technological advancement. In the previous example,
the man's age would in all likelihood have excluded
him from treatment of any type as late as the early
1970's. "Death committees" previously existed which
consisted of decision-makers determining who would
receive treatment and who would not. These committees
were comprised of medical personnel, clergymen, and
community leaders; individuals who were believed to
have expertise in the field, and/or possess high moral
standards. These committees based their decisions
upon the patient's age, contribution to society,
chances of survival, future potential, employment
record, etc. The committee choices involved a matter
3
of life and death for the patients requesting
dialysis, resulting in death for those not chosen.
The moral and ethical decisions faced by
professionals and families were numerous, and the
availability of kidney dialysis and transplantation
was inadequate and quite scarce. This continuing
dilemma caused many dedicated individuals to join
forces in an attempt to receive funding for those
patients afflicted with renal disease and to increase
the availability of the treatment modalities. The
result from years of hard work occurred in 1972 when
Medicare implemented coverage for the greater portion
of dialysis costs, and began the End Stage Renal
Disease Program (ESRD) to serve those afflicted with
kidney disease. To begin, the first chapter will
discuss ethical controversies encountered with "death
committees" and resulting legislation.
The ethical controversies faced by those in the
kidney disease field have been met by dedicated
researchers in an effort to improve the methods of
treatment for kidney patients. The advances in renal
medical technology will be discussed to indicate the
importance of further research in improving treatment
and also eventually finding a cure.
Elderly patients have been shown to present
varying symptoms when suffering kidney failure.
4
therefore it is essential for medical personnel to
have a thorough understanding of the differences
associated with aging from pathological changes in the
kidneys. This differentiation is also important to
the lay person, therefore, kidney disease specifically
focused on the elderly, evolution of various treatment
modalities, and the survival rates of elderly with
renal disease will all be incorporated in the
following chapter.
The older segment of our population is growing at
an astonishing rate, thus indicating the potential
impact this increase could have on the ESRD program.
The increased utilization by elderly individuals
presently in the ESRD program has directly increased
the program costs. Due to the numerous questions
surfacing because of the high costs of medical care,
there is currently a concentrated focus on ESRD to
affirm its effectiveness in various aspects of cost
containment and success measures (since it is one of
the largest life-sustaining technologies covered by
Medicare). Along with discussing cost factors,
(because it is a federally funded program) the
legislative issues will also be addressed regarding
the status of the program in the policy arena.
An important component involved with policy
making at any governmental level is that of possessing
5
influential lobbying power. This was developed for
kidney patients through individuals dedicated to renal
disease patients and their fight against kidney
disease. An example of this dedication will be
briefly discussed using the National Kidney Foundation
(NKF). This information will be presented to further
enhance the importance that grass-roots organizations
can have if they possess the required perseverence.
The aforementioned issues involved for elderly
renal disease patients will provide a basis upon which
a firm stance can be taken when viewing various
programs and theories in the arena of health care
rationing and apply this knowledge to the elderly
kidney patient. The ensuing discussion will include a
few specific economic theories of rationing, and, in
addition, a comparison of the U.S. ESRD program to the
National Health Service in Great Britain which will
further the understanding of the values inherent in
our health care delivery system. Lastly, a specific
example of a health care rationing proposal directed
toward the use of life-sustaining technologies with
the elderly will be evaluated.
The contemplation of rationing treatment
modalities to the elderly has resulted in ethical
controversy among not only those in the fields of
aging and medicine, but to essentially the general
6
population as the effects are felt by most everyone
who has contact with an elderly individual requiring
some form of life-sustaining technology, whether it is
dialysis or antibiotic treatment. The information and
statistical data which will be marshalled throughout
this thesis will provide firm evidence that rationing
of dialysis or transplantation to the elderly renal
disease patient in the United States is ethically
unacceptable and statistically unwarranted.
II. RENAL DISEASE IN THE ELDERLY
A. A BRIEF HISTORY-ETHICS AND LEGISLATION
The area of medicine involving renal disease
research has made tremendous strides over the past
thirty years. Prior to the 1960's, there was little a
physician could do when a patient experienced renal
failure (when kidneys lose capacity to function
properly). The development of the artificial kidney
machine to conduct kidney dialysis, followed by
increased precision in transplantation procedures,
were major strides in the treatment of renal disease.
However, although there were gains produced by the
research arena, issues of ethics, cost and
accessibility arose as crucial barriers to treatment.
The demand for hemodialysis began to increase as it
gained a valued place in treatment for renal patients.
This dilemma leads us back to the previous
discussion involving the "death committees" and the
ethics involved. The decision procedure used to
designate those able to receive treatment was
implemented as general practice across the United
States. To further emphasize the ethical basis which
instigated the 1972 Medicare legislation, consider, if
you will, the following scenario: It is the early-to-
8
mid 1960's and you are a member of a death committee
in a midwestern community which will determine the
fate of the following five kidney patients. Only 3
may receive treatment— which will you select?—
1. Jeff Anderson, Medical Doctor, divorced, lives in
the suburbs in a metropolitan area. Jeff has four
children, is 61 years old, and has been very active in
his community and considered a "good" doctor and
community man.
2. Stan Larson, taxi driver, married, two children
and is 35 years old. Stan is a hard worker, usually
taking two shifts to gain extra pay for his children
to have more than he did as a child. He has a strong
sense of pride and dignity when it comes to raising
his children without receiving charity.
3. Janice Underhill, single, school teacher, 25,
diabetic. Janice received the coveted award of most
valuable teacher in her school system. Janice has a
special gift of working with learning disabled young
people, in being able to relate to them and gain their
confidence.
4. Carolyn Thompson, housewife, 2 children, 43 years
old, college education. Carolyn is a professional
dancer, but has given up her career for the years her
children are young. Carolyn and her husband lead full
and active lives.
9
5. Rebecca Sanders, 11 years old. Rebecca has 1
brother that was born with the misfortune of being
severely mentally retarded. John, her brother, is
home, but the parents are being encouraged by
specialists to place him in a special facility.
Rebecca has been such a joy, the parents are
frightened, and beg for dialysis. — (These are
fictional characters and scenarios)—
There is no correct answer in this exercise, it
is obviously a judgement call based on your
perspective and attitude toward the particular
individuals described. It was not then, and would not
presently be an easy decision to make. Death
committees were believed to be the most reasonable
procedure to decide on the relative merits of
treatment for applying patients at a time when there
was a scarcity of dialysis machines, and kidney
transplantation was in the initial stages of success
as a treatment modality. Until treatment capability
could meet the demands, the agonizing decisions
concerning patient selection were inevitable.
The need for additional access to treatment for
kidney disease was becoming more evident. It was
extremely frustrating to those professionals in the
kidney field who knew how to prolong life, but were
unable to do so because of insufficient funding
10
sources available. The death committees and
situations previously described were major catalysts
for the initiation of efforts by lay people to
alleviate such life or death decisions. The field of
kidney disease not only involves dedicated medical
professionals and afflicted patients, but also
concerned family members and friends of those
afflicted patients. These groups joined forces in the
1950's in order to become an effective voice for the
kidney patient. This was the beginning of the formal
organization which we know today as the National
Kidney Foundation which continue to play a significant
role in advocacy for renal patients (See Chapter V for
further description).
The late 1960's played a significant role in the
legislative history of renal disease. A few critical
pieces of legislation which strongly impacted the
future of renal disease treatment were implemented.
In 1965, the Medicare Act was passed in order to help
alleviate health care costs of elderly in the United
States. The passage of Medicare encouraged those in
the renal disease field that perhaps the government
was making a concerted effort to aid patients by
covering expensive health care costs, and that there
was some hope to gain funding for renal disease
patients. Another encouraging policy development was
11
the drafting and approval of the Uniform Anatomical
Gift Act in 1968 which encouraged the development of a
uniform tissue donation card to be carried by those
Americans who chose to donate organs upon death.
During 1969, the NKF developed a Uniform Donor Card
which works in conjunction with the Uniform Anatomical
Gift Act, allowing the kidneys of those who possessed
donor cards to be utilized for transplantation
procedures in order to increase the ability to conduct
transplants. Due to the tremendous need for organ
donors, this was a crucial piece of legislation for
those qualified for kidney transplants. During the
year 1970, over two million kidney donor cards were
distributed alone by NKF, with over 5 million in total
distributed by 1970.
July 1, 1972, is one of the most memorable days in
history for those afflicted with end stage renal
disease. On this day. President Richard M. Nixon
signed into law H.R.-l, amending the Social Security
Act with eight simple words which gave new hope to
thousands of kidney patients, "chronic renal disease
is considered to constitute disability." This law
made dialysis and transplant patients eligible for
federal assistance to alleviate a majority of the high
costs of health care associated with these treatment
modalities. The ESRD program offers almost a complete
12
entitlement to those individuals afflicted with renal
disease, so they have the opportunity to receive one
of the treatment modalities (Maxwell, 1987). Medicare
covers 80% of average costs for outpatient treatment
either at hospital based or free-standing facilities.
The burden was lessened further as many state Medicaid
programs began paying the 20% which remained. Home
dialysis is reimbursed on a reasonable cost basis
(relying on standard payment procedure) as transplants
are also (Maxwell, 1987).
The NKF and medical professionals dedicated to
fighting kidney disease played major roles in
increasing treatment access and availability for
kidney patients through the previously discussed
legislation. The ethical decisions involved when
considering requests for dialysis were considerably
diminished. However, as age was a vital criterion
used in the decision process, it is beneficial to gain
firm background concerning overall kidney function in
the elderly and the alternative treatment options when
one's kidneys fail to function sufficiently.
B. KIDNEY FUNCTION AND RENAL FAILURE
The process of aging is one arena which poses
many challenges for the medical profession, both at
13
present and in the future. The demographic increase
of the elderly in our society indicates the need for
further knowledge and understanding in geriatrics and
gerontology. Evidence reveals that the evaluation of
the health of an older person requires additional
expertise to distinguish the normal changes of aging
from pathological changes. Although knowledge
concerning normal aging changes is not exact, there is
considerable information with regard to the changes
associated with age. As discussed by Kane et al.
there are significant changes with age in most systems
of the body (Kane et al., 1984). The specific changes
in kidney function in relation to the elderly will be
the focus of the remainder of this chapter. The
following sections will provide an introduction to
issues involved with kidney function, treatment
modalities used in renal failure, and the survival
rates associated with the elderly patient.
With increasing age, the kidney will incur both
anatomical and physiological changes. These changes
which involve progressive loss of function and renal
mass, however, usually are of little significance
revealing no signs or symptoms in what are considered
relatively healthy individuals (Feinstein, 1986). On
average renal function declines by approximately 50%
between the ages of 20 and 90 years (Kane et al.,
14
1984) .
When kidneys are healthy they are the regulators
of the body's water and salts, and also excrete the
by-products of metabolic activities and urine. The
kidneys also produce and release hormones into the
bloodstream which regulate blood pressure, calcium and
phosphorous metabolism, and the production of red
blood cells (Office of Technology Assessment, 1987).
When impairment in renal function occurs, it may
be due to problems with the kidneys themselves, or
because disease is present in other organs.
Impairment may be caused by pathological problems, or
normal age-related physiological processes. In the
absence of disease, normal aging involves the
progressive loss of renal function which begins in
early adulthood (Office of Technology Assessment,
1987) .
The warning signs for kidney failure include high
blood pressure, more frequent urination particularly
at night, etc. (See Table 1. Warning Signs of Kidney
Disease). However, the warning signs for renal
failure in the elderly can be ambiguous unless the
patient is obviously overtly uremic. As physicians
trained in the field of geriatrics know all too well,
presenting symptoms in the elderly patient can be
deceiving indicating a greater need for further
15
testing (See Table 2. Diagnostic Problems of Renal
Disease in the Aged). The elderly patient may present
with one or more of the typical features of uremia
(the symptomatic phase of renal failure) however,
presenting symptoms may be that of an underlying
disorder which is placing the kidney at risk or they
may be nonspecific indicators such as nausea,
vomiting, and weakness (Rosen, 1976).
The most prevalent indicators of renal failure
are obtained through blood-testing (urea, creatinine,
electrolytes, calcium and phosphorous) and urinalysis.
The most clinically employed measure for renal
dysfunction is the estimate of the glomerular
filtration rate (GFR). Numerous studies have
indicated there is a gradual reduction in GFR with
increasing age. Rowe et al (1976) employed both cross
sectional and longitudinal studies and found there was
a significant reduction in creatinine clearance in
relation to age. He discovered a decline beginning at
age 34 and accelerated after age 65. Therefore, the
decline in GFR is a major factor during the kidney
function evaluation process, but is difficult to
obtain an accurate measure to establish age adjusted
standards.
When the decrease in an individual's renal
function is so severe that it is incombatible with
16
life, he/she is experiencing renal failure. In
considering the cause of renal failure, the first task
is to determine whether the process is a progressive
chronic condition, is acute in onset, or if it is
simply a reflection of an acute deterioration of renal
function being superimposed upon chronic renal
disease. The patient's history is of great importance
in differentiating between acute and chronic process
to determine possible past experiences or relatives
possessing a history of kidney disease (Oken, Wolfert
and Sica, 1985).
Acute renal failure is sudden, but fortunately is
potentially reversible and renal functioning can be
restored. It may be caused by various diseases, by
drugs which are toxic to the kidneys, surgery, trauma,
reduction or cessation of blood flow to the kidneys,
or by the flow of urine being obstructed (Freeman,
1986). If acute renal failure (ARF) develops, the
older patient is usually treated the same as younger
patients. Attention will be addressed to electrolyte
imbalance, particularly hyperkalemia; volume overload,
which could precipitate pulmonary edema; and also
various infections, which usually exacerbate an
existing state (Feinstein, 1986).
The management of acute renal failure in the
elderly can be complex and demanding (but it is
17
possible to return kidney function again to the
individual). The aged kidney retains the remarkable
capacity to recover from acute ischaemic or toxic
insults over a course of several weeks (Sourander and
Rowe, 1985). Temporary dialysis treatment can restore
normal kidney function for those afflicted with acute
renal failure. However, some people die as a result
of the underlying disease or disorder which caused the
renal failure, or acute renal failure can also be the
prelude to chronic renal failure. Therefore, as
previously discussed, the evaluation determining the
cause of the acute onset is crucial. There are
precautionary measures which can be implemented that
aid in preventing the onset of acute renal failure,
such as maintaining adequate extracellular fluid
volume or using discretion if taking non-steroidal
inflammatory agents (See Table 3. Prevention of Acute
Renal Failure).
Chronic renal failure (CRF) is irreversible and
usually indicates the progrèsive decline of kidney
function. CRF refers to the decline in the glomerular
filtration rate seen in a variety of diseases
affecting the kidney. CRF can also be caused by a
multitude of known and unknown factors, with some of
these including immunological, diabetes mellitus and
hypertension (Feinstein, 1986).
18
There are various stages of CRF ranging from mild
renal insufficiency (loss of approximately 25% to 30%
renal function) to advanced renal failure (loss of
80%-90%). End-stage renal disease is that stage of
CRF which requires either dialysis or transplantation
(usual denotes less than 5% of normal renal function)
to sustain life (Feinstein, 1986). The management of
CRF prior to the development of end-stage renal
disease can be obtained through the implementation of
various measures (See Table 4. Nondialytic Management
of Chronic Renal Failure). For example, the
restriction of protein early in the course of CRF is
being studied as an attempt to slow the progressive
loss of renal function (Brenner, Meyer and Hostetter,
1982) .
To the renal physician the methods of treating
kidney disease are all too familiar. It is recognized
that most patients who are afflicted with ESRD have
experienced reduced renal function over a period of
time and, for many, the need for renal therapy comes
as an unpleasant but necessary course of action (U.S.
Department of Health and Human Services, 1987). New
advances, particulary in hemodialysis and
transplantation, have improved the prognosis for the
older patient whose kidneys have failed, and these
advances have tremendously increased the outlook for
19
the future (Feinstein, 1986).
Knowledge gathered from further research will
hopefully increase our diagnosis of actue renal
failure prior to reaching the chronic end stage of
renal disease. Difficulty has been shown in
differentiating aging processes from pathological in
diagnosing kidney problems with the elderly. Elderly
individuals who are afflicted with ESRD require
careful evaluation due to their varying presenting
symptoms in order to ascertain the most favorable form
of treatment. This dilemma further emphasizes the
fact of the need for increased training in the medical
profession in aspects of renal disease in elderly.
A number of factors must be considered in
deciding upon which therapy will be implemented for
the elderly patient with end stage renal disease.
These should include aspects of medical, dialysis-
related, psychological, social and various ethical
concerns (Oreopoulous, 1984). This approach ensures a
thorough evaluation for each particular patient to
determine the most appropriate treatment. The
treatment modalities of hemodialysis, peritoneal
dialysis and transplantation will be discussed to gain
a better understanding of the alternatives kidney
patients, families, and physicians encounter when
deliberating appropriate treatment for an individual.
20
Medical developments and recent studies will also be
addressed along with their relation to and impact on
the elderly patient.
C. TREATMENT MODALITIES
1. Kidney Dialysis
There are two main types of dialysis which are
utilized to provide effective artificial kidney
function in the event of end stage renal disease. The
procedures are 1) hemodialysis, and 2) peritoneal
dialysis. Elderly patients are more often introduced
to hemodialysis, but peritoneal dialysis, as will be
shown, can also be a viable option for appropriately
evaluated patients (Sourander and Rowe, 1985).
a- Hemodialysis
At present, the oldest and most prevalent method
of dialysis used for ESRD patients in this country is
hemodialysis (Office of Technology Assessment, 1987).
The majority of patients over the age of 60 with renal
disease are being treated with maintenance
hemodialysis. With the increasing numbers of the
older segments of the population (See Chapter III) it
is evident this form of treatment will continue to be
crucial for those elderly afflicted with ESRD until a
cure is found for renal disease.
21
Prior to the initiation of maintenance dialysis,
a pathway must be formed to provide a route for blood
to pass through the artificial kidney dialyzer and
then returning it to the individual. To accomplish
this, an artery (providing a route for blood to flow
from the heart) and a vein (providing a route to
return blood to the heart) are used to provide access
through either shunts or fistulas.
In the early years hemodialysis required a new
arterial and venous cutdown in order to gain access
into the patient's bloodstream at each dialysis
treatment episode (Office of Technology Assessment,
1987). Fortunately, in the early 1960's, Scribner and
his colleagues at the University of Washington
developed a Teflon arteriovenous shunt which offered
maintenance hemodialysis as reality for patients with
chronic renal failure (Blagg, 1986). A shunt
resembles a U-shaped tube in which one end is placed
in a vein and the other into an artery. This provides
a pathway for blood flow during dialysis. Shunts are
usually placed either in the forearm or ankle.
Due to problems with the shunt (such as
bloodclotting, infection, etc.) research continued to
look for access alternatives for dialysis, and in
1966, the arteriovenous fistula was created. It is
similar to a shunt, utilizing an artery and a vein
22
which are surgically connected under the skin. Most
fistulas are surgically created on the arm (near the
wrist) or the upper leg. Subsequent developments and
refinements in the fistula have resulted in shorter
dialysis time, increased safety, economic savings, and j
greater comfort for the patient. The veins of some
patients will not permit the creation of a fistula, I
but fortunately through continued refinements a
variety of grafts are now possible; however, the
"native" arteriovenous fistula continues to be
considered the "gold standard of blood access" (Blagg,
1986).
The establishment of vascular access could be a
major problem in the older patient because of the
greater degree of peripheral vascular disease expected
in this group. This concern may be a serious problem
in a select number of patients, but most authors have
not reported that it was great enough to limit or
hinder hemodialysis in the elderly (Stacy and Sica,
1985).
The process of hemodialysis involves pumping
blood out of a patient's body into a dialyzer where
impurities are removed, then returning the blood to
the patient's body. For most patients, treatments are
conducted three times a week for 3-5 hours each time,
however, some patients require more frequent dialysis.
23
Hemodialysis can be conducted in a hospital, free
standing dialysis center, or in the patient's home
(Office of Technology Assessment, 1987). The elderly
population is usually not able to dialyze at home due
to additional complications. The fear of comorbid
conditions are a concern of the elderly on dialysis.
The increase in the number of ailments with age could
have an impact on mortality and possibly reduce
survival of those on dialysis (See Section D on
Survival Rates). Reasons why elderly (or any age
group may not be considered for home dialysis include
the lack of proper social support (spouse,
family/friends to assist), poor motor skills, or other
secondary medical problems.
The technological advances in hemodialysis have
been tremendous since the early 1960's. Hemodialysis
is considered the most appropriate treatment for the
majority of the elderly by their physicians. This
could be due to the experience and knowledge base that
the longer history of hemodialysis allows, and also
the ability to control more factors. The continued
implementation of hemodialysis will further enhance
current knowledge and hopefully continual refinements
on the procedure will increase the comfort and success
the elderly patient endures while undergoing this
treatment. Another form of dialysis in which
24
utilization is increasing is peritoneal dialysis.
b. Peritoneal Dialysis
The second major form of renal dialysis treatment
is peritoneal dialysis (Blagg, 1986). This treatment
modality for ESRD uses the patient's peritoneum (the
semipermeable membrane surrounding the abdominal
organs and lining of the abdominal cavity) to perform
dialysis within the patient's body (Office of
Technology Assessment, 1987).
In the early 1960's, the first trials of
peritoneal dialysis were conducted in hopes of
improving the management of chronic renal failure
(Stacy and Sica, 1985). Peritoneal dialysis remained
an impractical method of long-term management method
of the ESRD patient until the introduction of an
acceptable chronic indwelling peritoneal catheter by
Tenchkhoff and Schecter in 1968 (Tenchkhoff and
Schecter, 1968).
The utilization of chronic peritoneal dialysis
has expanded in recent years from a treatment
performed mainly in a hospital to an effective and
popular mode of out-patient therapy. The increase in
out-patient usage is largely due to the use of plastic
bags instead of glass bottles in which the dialysis
fluid is housed, the Tenchkhoff and other such
25
indwelling permanent catheters, and the automatic
dialysate cyclers which reduce the number of necessary
changes of the dialysis fluid containers (Feinstein,
1986).
The various methods used in peritoneal dialysis
include chronic peritoneal dialysis which may be
intermittent (IPD); continuous cycling (CCPD); or
continuous ambulatory (CAPD). It depends on time and
location factors in determining which is most
feasible, but continuous methods are generally
utilized at home and intermittent dialysis is usually
conducted in a center or hospital (Office of
Technology Assessment, 1987).
Intermittent peritoneal dialysis (IPD) was the
technological precursor to both treatment forms of
CAPD and CCPD. It was recognized that although
certain patients did well on IPD, the modality was
limited in its applicability due to the process
involved with IPD (Mion, 1983). IPD utilizes a
machine which delivers the sterile dialysate into the
peritoneal cavity of the patient for a specific amount
of time, and then the dialysate is removed. IPD
requires a treatment time of 10-12 hours, 3 nights a
week. On IPD, treatment is considerably longer than a
regular hemodialysis treatment.
In 1978, a new era in dialysis began when
26
Popovich and coworkers presented their findings on the
CAPD procedure. Today, CAPD is the most popular form
of peritoneal dialysis and is primarily used at home,
accounting for over 13% of all dialysis patients in
the United States (U.S. Department of Health and Human
Services, 1985). In CAPD treatment the patient will
exchange dialysis fluid usually four times daily.
Because the dialysis is carried out non-stop around
the clock, it allows for less fluctuation in the
concentrations of uremic metabolites and electrolytes,
and thus reduced weight gain due to accumulation of
fluid (Feinstein, 1986). A variation on the CAPD
procedure is called cyclical peritoneal dialysis
(CCPD). CCPD allows approximately three to five
exchanges to take place throughout the night with the
assistance of an automatic cycler, and with the last
exchange remaining in the abdomen during the day
(Kaye, 1983). Two main groups of investigators have
introduced this form of treatment (Diaz-Buxo et al.,
1981; and Adams et al., 1981). One group refers to
the treatment modality as automated long cycle
peritoneal dialysis (ALCPD), while the other prefers
CCPD. Both of these methods are the same with the
réintroduction of the use of a machine, namely a
cycler which delivers three to four exchanges of
dialysis solution over a period of 9 to 10 hours
27
during the night. Upon disconnection in the morning,
the dialysis solution remains in the peritoneal cavity
for 12 to 14 hours (Drukker, 1983). As Drukker notes
in his discussion, it is believed the results of this
technique equal those found with CAPD, and are
superior to the use of IPD based on the process and
time entailed. The procedure is still under evaluation
and Diaz-Buxo et colleagues have There are many
conclusions being drawn and Diaz-Buxo et al., (1981)
have specifically listed their conclusions on the
benefits of CCPD. An example includes having only one
connection at night and one connection in the morning
substantially reducing the risk of peritonitis (an
infection which can develop if not monitored).
In the beginning of CAPD, older people were not
viewed as good candidates for this treatment modality,
because there was concern as to whether they possesed
the necessary capabilities to master the various
tubing changes due to possible physiological changes
with motor skills ability and declines in vision
(Stacy and Sica, 1985). However, the use of CAPD, as
is true with other treatment modalities, is considered
on an individual basis to ensure it is the most
effective form of treatment.
The concept that the elderly patient would not be
a viable candidate for CAPD was challenged by
28
researchers in the field. Kaye et al. reported
favorable results in a small series of CAPD patients
over the age of 65 years of age. In their population
of 44 patients who were successfully oriented and
trained for CAPD treatment, the 18 patients who were
65 years old (mean age of 73.7) did just as well as
the 2 6 patients who were under 65 years old (mean age
of 48) (Kaye et al., 1983). Therefore, it appears
from this study that age does not play a significant
role in the success of the procedure. Success is
often measured by survival rates, but one must address
the fact that age is only one criterion to consider
when evaluating the survival rates. Other
researchers optimistically feel that peritoneal
dialysis is an excellent alternative for the older
ESRD patient, being particularly applicable for older
patients who prefer and are able to have home
dialysis. For those with an active lifestyle the
simplicity and flexibility of this treatment offers
much more freedom than other dialysis procedures
(Stacy and Sica, 1985).
The advancements in peritoneal dialysis offer
those afflicted with renal disease another treatment
alternative. Further research on elderly patients is
needed to further substantiate the findings by
researchers concerning elderly undergoing peritoneal
29
dialysis. While dialysis is crucial and utilized by
the majority of the elderly ESRD patients, transplants
are beginning to increase among those over age 55.
This is an exciting development in the renal disease
field and could prove important with the increasing
numbers of elderly over the next thirty years.
2. Kidney Transplantation
For patients with ESRD a kidney transplant can
alleviate pain and suffering and as Wood (1983)
states.
Transplantation is the ideal treatment for
chronic renal failure. The patient can be
completely rehabilitated and freed from the
practical and psychological problems of long
term dialysis. Although hemodialysis is a life-
saving procedure, the dependence on the machine
means a very restricted lifestyle.
Kidney transplants are described according to the
source of the donor kidney. The two sources of
transplant kidneys are either living (usually related)
donors, or a cadaveric donor (graft is from a brain
dead cadaver). Living related donors generally have
higher success rates (See Section D- Survival Rates),
which will be discussed in the next section.
In the past, candidates for transplant were
ideally between the ages of 16 and 45 and had no
complicating disease (Vital Statistics, 1980). Many
30
physicians continue to believe that transplants are
risky for the elderly due to the increased incidence
of comorbid factors, but can still be a viable option
depending on the individual (See Chapter VII-Views
From Renal Disease Experts). The assessment procedure
for kidney transplantation is quite extensive,
especially for the elderly. Wood (1983) recommends a
number of areas such as family history, previous
infections, etc. (See Table 5. Assessment Information
to Obtain From Transplantation Candidate) in which it
is vital to obtain information during the assessment
for transplantation. The evaluation process is crucial
in transplantation. There may be tremendous amounts
of information to gather, but the entire history is
needed in order to obtain a successful graft. The
patient undergoes extensive physical(laboratory) and
psychological(stress) tests to determine their fitness
of undergoing this major surgery. The number of
overall kidney transplants increased from 75 in the
years 1951-62 to 6,112 in the year 1983. Although the
number of patients over 45 receiving transplants is
still relatively low, this number has begun to
increase over the past twenty years.
Although precautionary and evaluation measures
are administered prior to and following
transplantation, the risk of rejection of the
31
transplanted kidney remains. In most cases clinical
complications such as fever, weight gain, etc. (See
Table 6. Classic Characteristics of Rejection)
develop, it will be within the first year following
transplantation. However, the diagnosis of rejection
can prove to be very complicated, not only with
elderly, but in other age groups as well. These
characteristics are not always fully expressed and
allow adequate diagnosis. However, the factors which
appear most reliable in determining rejection are
weight gain and decreased urinary output. The elderly
are a population for which it is essential to make a
firm rejection diagnosis to avoid possible
complications of steroid toxicity (Baquero and
Goldman, 1985).
When patients obtain a kidney transplant they
inherit the responsibility of following a strict drug
regimen (for the rest of the life of the graft) to
deter their body from rejecting the kidney. The
medication works as a guard against the body's battle
to rid the individual of the foreign body which was
placed in their abdomen. The most widely utilized
immunosuppressive agents after transplantation are
azathioprine and steroids.
A major development for kidney transplantation is
the new immunosuppressive agent, cyclosporine. This
32
drug could have tremendous effects on patient
selection criteria and the drug regimen patients are
subjected to after transplantation. Ringden et al.
have found that with the use of cyclosporine it is
possible to permit better patient and graft survival
in the older age group (Ringden et al., 1983).
Although research continues on the use of
cyclosporine, especially its side effects, it appears
that a lower dosage of steroids (than would normally
be taken by the patient) are required when used in
combination with cyclosporine. Therefore, there is a
decrease in the development of steroid-related
complications (Baquero and Goldman, 1985).
The benefits of kidney transplantation relative
to risks continues to be questioned for the elderly
patient by some physicians. This treatment modality,
as with forms of dialysis, is considered on an
individual basis when determining treatment options.
As stated previously, the perceived success of a
procedure is clearly related to its survival rate
statistics. The following section will address
outcomes of dialysis and transplantation for the
elderly kidney patient.
33
D. SURVIVAL RATES AND OUTCOMES OF ELDERLY WITH
RENAL DISEASE IN THE UNITED STATES
The issues of survival rates and outcomes among
the elderly with chronic disease are very complex and
will be discussed only briefly due to their
complexity. It is true that there has been a decline
in mortality from diseases which kill middle-aged and
older men and women (Crimmins, 1981). However, at
present chronic conditions are the most prevalent
health problems, whereas acute conditions predominated
in the past. Today, the leading chronic conditions
include hypertension, arthritis, and heart conditions
(U.S. Department of Health and Human Services, 1987-
88) .
When analyzing major forms of life-sustaining
technologies for the elderly such as kidney dialysis
and transplantation, it is essential to take a close
look at survival rates and outcomes among those
patients afflicted with this chronic disease. The
recent concentration on the benefits of dialysis and
transplantation draws the question of what the
treatments and costs entail. Thus, Morris (1979)
states.
Dialysis and transplantation are costly
treatments and in recent years every
western country, faced with rapidly rising
medical costs, has reflected about the cost-
effectiveness of expensive therapies.
34
Inevitably the spotlight has fallen on dialysis
and transplantation. Is this justified?
The answer to this question is indicated through
the survival rate information which follows.
Past research studies, it is important to note,
have utilized cross-sectional designs to indicate a
number of parameters differing with age in kidney
disease. Of course errors can occur in cross-
sectional designs and one must be aware of this when
analyzing results. Some of the major precautions
include the concept of "selective morbidity" developed
by Andres (1969), and also the chances of overlooking
some subclinical renal impairment which could be
adversely affecting kidney function. When one views
cross-sectional material it is vital to note that a
subject pool perhaps over the age of 75 are from a
cohort which has experienced at least a 75% mortality.
Therefore, survival related variables (whether it is a
risk factor or possesses a protective effect) in
cross-sectional data can show age-related differences
are not really the effect of age. To overcome these
research difficulties the need for longitudinal study
data is apparent (Epstein, 1985).
The survival rates of patients suffering from
ESRD who are on dialysis treatment are dependent on
the following criteria: cause of renal disease,
35
presence of preexisting disease(s) upon initiation of .
dialysis, and the age upon dialysis initiation (Blagg,
1986). The patient's probability of survival on I
dialysis is significantly associated with the cause of |
renal failure (U.S. Department of Health and Human j
j
Services, 1987). There are numerous complications
which can affect survival among dialysis patients. j
These can range from cardiovascular disease to bone i
diseases, and the older population tends to have more j
!
chronic diseases than the younger population (Office j
of Technology Assessment, 1987). In 1985, the leading
diagnosis of older patients on dialysis who died was |
hypertension accompanied by heart and renal disease '
(the data indicated this in 35.7% of those who died at !
I
both 65-74 and those 75+) (U.S. Department of Health
and Human Services, 1985).
A recent study by Walker et al. compared patients I
over age 50 to those under 50 years of age on \
I
1
dialysis. A primary question addressed was whether
survival rates were in fact correlated with age. The i
population was predominantly male and between the ages ,
I
of 50 and 74. The mean survival rate for the first
three years were similar in both the 50+ and the under
I
50 age groups. Thereafter, however, the older
patients did have an increased mortality. Results
also indicated that for those patients over 50 on ;
36 I
self-dialysis, the survival rates were much higher
than those dialyized in-center. This appears
consistent with the findings that the majority of
individuals receiving treatment in-center possess more
complications than those using home dialysis. Walker
concludes that age should not be a significant
deterrant to hemodialysis. It was demonstrated that
for the first three years the patients over 50 years
of age possessed a mortality rate similar to the
younger group (3 year survival, 64%) (Walker et al.,
1976).
When elderly individuals are considered for kidney
transplantation, the fact that those over age 50 tend
to possess numerous associated diseases becomes a
crucial factor (Baquero and Goldman, 1985). This fact
results in many physicians opting not to use
transplantation as a viable alternative to dialysis
for the elderly.
A study by Kjellstrand et al. based on data from
the transplant procedures they accomplished in
patients over the age of 50 years found that kidney
transplants from related donors had the same high rate
of success that younger patients achieve. The
differences between related donors and cadaveric donor
statistics were demonstrated and revealed, not
surprisingly, that survival rates were much higher
37
with donor-related than cadaveric donors. The
cumulated survival rates over five years was 80% for
related donor patients and 43% for cadaveric patients.
Kjellstrand believes that elderly patients should not
be denied the ony known cure (transplantation) because
of age or other chronic diseases. He feels that the
major emphasis should be placed on determining which
patients would develop cardiovascular problems after
dialysis or incur infection after cadaveric
transplantation as these are the leading causes of
death in those treatment procedures (Kjellstrand,
1976).
It can be difficult to find a related donor other
than children because parents probably will not be
living and siblings tend to be close in age and
possess complicating diseases. Physicians hesitate to
risk the donation of a kidney by a relatively young
child to an aged parent. According to Kjellstrand's
study, if kidney donation by relatives were
discontinued, the only choices would be cadaveric
donation or long-term dialysis, which both possess
twice the mortality rate of donor-related transplants
(Kjellstrand, 1976).
A recent study by Terasaki with UCLA
demonstrated a direct correlation of an increase in
graft survival with age. This indicates that the
38
older the patient when receiving the transplant, the
higher their chances of the graft lasting (Terasaki,
1988).
The previously reported data appear to indicate
acceptable survival rate statistics for kidney
transplantation in the elderly. The donor-related
statistics are especially encouraging, however, also
entail some ethical dilemmas faced by physicians.
Another very controversial issue which tends to
receive a great deal of attention is that of "quality
of life" as an outcome experienced by a patient either
receiving dialysis or a transplant. This measure can
be very arbitrary and requires caution in its
utilization for treatment allocation. A study for the
Department of Health and Human Services involved an
extensive and complicated study to attempt to
determine the quality of life for patients under the
various forms of treatment. The study involved the
variables related to objective measures such as
ability to work, and subjective measures such as
psychological effect and their relationship to the
quality of life of the patients. It was found that
transplant patients reported a higher quality of life
than any of the various dialysis patients. These
findings appear consistent with the fact that
individuals (of any age) who receive a kidney
39
transplant can basically lead a life similar to others
free of kidney disease. Whereas those on dialysis are
subject to a strict routine requiring machines to
sustain life (U.S. Department of Health and Human
Services, 1987).
The survival rates of dialysis and
transplantation appear to offer substantial evidence
that these treatment procedures are successful in the
elderly population. There are a number of factors to
consider when choosing a treatment modality for an
afflicted individual, but age should not be a
precluding barrier to receiving treatment of any type.
The increase in the patient population further
warrants this belief as more will be utilizing the
ESRD program in the future.
III. PATIENT POPULATION AND UTILIZATION
Examining the age distribution in the U.S., we
see a continued increase among the 65+, with the
largest increase within the 85+ segment of the
population (U.S. Department of Health and Human
Services, 1987-88). Accelerated growth is expected in
this population in the first twenty years of the 21st
century, and these increases, reflect the middle-
aging and aging of the post WWII baby-boom cohort. The
same aging trend is indicated when viewing statistics
40
of the Medicare ESRD patients by age (See Table 7.
Medicare program enrollment by age, 1979-84). It
shows the phenomenal increase during 1983-84 of 11.3%.
It appears that the program is increasing in
population most significantly from ages 45 and above.
It should be noted that the age group 25-44 is
considered part of the baby-boom cohort and is a large
group which will be entering middle to older age
during the next twenty years.
Evans found some interesting changes in the
characteristics of the ESRD population when comparing
the population prior to the 1972 legislation to
present. In 1967, only 7% of dialysis patients were
55 and older, but by 1978, this proportion had
increased to 46% (Evans, 1981). From these dramatic
increases in the older patient population, one could
draw the conclusion that there were many older
patients unable to afford or gain access to treatment
prior to the ESRD legislation. Another possibility
includes an overall increase in the reporting of renal
disease. These possibilities in conjunction with the
increases in the older population and more prevalence
of chronic disease are causes of the acceleration in
growth of the elderly population under ESRD coverage.
In 1985, Medicare's ESRD program served a total
of 90,621 dialysis patients. In addition, there were
41
6,938 transplants. Almost a third (31%) of all kidney
patients were over age 65 in the ESRD program. The
numbers of new dialysis patients who are older has
increased faster than any age group, with annual
percentage increase from 1980-84 of 11.7% of those 65-
74 and 2 0.7% for patients 75+ (U.S. Department of
Health and Human Services, 1985).
The growth in the overall dialysis population can
further be examined through the type and place of
dialysis treatment. From 1980-85 the average growth in
the total population was approximately 10%. The use
of CARD demonstrated an average of approximately 3 7%
per year and in-unit hemodialysis 10% (U.S. Department
of Health and Human Services, 1985).
The utilization of dialysis by the elderly has
increased substantially in the past fifteen years.
This increase is correlated to the increase in the
overall elderly population, and also by the ESRD
legislation of 1972. The utilization by the elderly
of the various dialysis modalities will apparently
continue to escalate in the years ahead.
The elderly are rarely able to home-dialyze due to
the rigorous treatment procedure, therefore are more
likely to require in-unit hemodialysis (hospital or
private) which can directly increase the per capita
cost expenditures encountered by Medicare. The
42
following chapter will briefly discuss the continual
battle the ESRD program faces in increasing medical
expenditures.
43
IV. TREATMENT COSTS AND LEGISLATIVE ISSUES IN ESRD
Health care costs encountered by Medicare are
increasing at a phenomenal rate. The percentage of
the Gross National Product allocated to medical care
in 1982 was 10.5%, 11.2% in 1987, and predictions for
1988 are 11.5%, or in excess of $550 billion (Altman
and Rodwin, 1988). The ESRD program is only one
segment of the health care expenditures under
Medicare, but all are under scrutiny and evaluation
due to the accelerating rate of growth in spending.
As stated previously, the elderly are an
important segment of the population to analyze when
health care expenditures are discussed. Schneider
(1988) expresses that health care costs incurred per
person increase as a function of age. He further
emphasizes that among our older age groups, health
care costs increase rapidly with compounding age.
Therefore, when viewing the overall picture without
proper knowledge, the situation arises when some
individuals blame the elderly for the majority of the
cost increases. Aaron and Schwartz, however, warn
that although we are losing the battle against
containing medical expenditures, it has little to do
with the elderly. In his reference to the increase in
the elderly population he believes that between the
44
present and the year 2000 they will not be a
significant contributor to the cost dilemma. In fact,
it can be calculated that they will only increase
costs by approximately .2 percentage points per year
(Aaron and Schwartz, 1984).
It is important in analyzing the present
situation of our health care delivery system that we
understand the time period in which the ESRD program
was initiated. There have been many changes over the
past ten to twenty years in such areas as policy,
population and medical technology involving renal
disease. Caplan (1981) feels it is important to
examine the attitudes and knowledge involved with ESRD
during the 1960's and 1970's and to further understand
the reasoning during the introduction of the ESRD
legislation. Caplan believes that when discussion
arose to debate funding for renal disease treatment
that dialysis and transplantation were rather
ambiguous in their utilization status and classified
somewhere between experiment and therapy to many
health care professionals. In the late 1960's
dialysis was proven an acceptable technique and was
mastered in the late 1970's. Along with the
technological advances it is essential to look at the
population utilizing the treatment in the past. In
the late 1960's, the majority of dialysis recipients
45
were young (25-45), middle-class persons with no other
illnesses. In the words of a physician stated in
Caplan (1981), "We had what was in many ways an
idealized population. A large fraction of the
patients were living in a productive period of their
lives. They were young and had little else wrong with
them". However, the demographics of the population
changed in the mid-to-late 1970's. The ideal
population was now growing older, more older
individuals were now covered by ESRD and perhaps
younger (more ill) patients were broadening the
spectrum of the population. As stated previously,
with age come further diseases, thus these additional
complications and expense. Also, prior to the ESRD
legislation, candidates who were very ill, frail, etc.
were not chosen to receive treatment, thus additional
costs had not previously been a major factor.
This change in the population and increase in
service utilization was obviously not anticipated or
considered when the initial law was passed in 1972.
Eggers (1984) believes that the increases in Medicare
expenditures between 1974 and 1983 were primarily due
to the increase in the number of beneficiaries. Since
its inception the ESRD program has seen an increase in
total expenditures and the number of beneficiaries.
Medicare expenditures on ESRD show a per capita rise
46
from $14,300 in 1974 to $21,051 in 1984. However,
when adjusted for inflation these figures for the two
years were almost equivalent (Office of Technology
Assessment, 1987).
The following remarks by Richard Rettig
(presently with the Institute of Medicine) vividly
express the sentiments of many of those in the field
of renal disease toward ESRD. Rettig (1980) states,
"This program claims our attention because life-
saving medical treatment is being provided to a
very small number of beneficiaries at a very
high cost to society, the result of public
policy to affirm the value that life is beyond
price even though such affirmation requires
substantial public resources."
He further discusses the congressional intent of the
1972 legislation,
"...the amendment was to provide access to life-
saving therapy for all who needed it where the
costs of treatment were beyond the means of
practically all individuals— in providing
access,the underlying rationale was to resolve
the "tragic choice" between this allocation of
scarce resources and the value of human life"
(Rettig, 1980).
Due to the increase in program expenditures which
were obviously unanticipated when the ESRD program was
implemented in 1972, Congress has now attempted to
limit ESRD expenditures. They have implemented
specific provisions which encourage home dialysis
(least expensive form of dialysis) and transplantation
(cost effective when successful) and have begun
establishment of composite reimbursement rates for
47
services rendered under ESRD (U.S. Department of
Health and Human Services, 1987) .
Cost and legislative issues are topics which are
of great importance for professionals involved with
renal disease in policy arenas. The National Kidney
Foundation, (NKF) a grassroots volunteer organization
is an example of a group of dedicated professionals
and volunteers from many vocations who have joined
together in the fight against kidney disease.
Although this group also deals with other areas in
kidney disease (research, education, etc.), their
impact on public policy for the renal disease patient
has been significant. The following chapter will
offer a brief discussion of the history of the NKF and
various accomplishments over the past twenty years.
48
V. PATIENT ADVOCACY- THE NATIONAL KIDNEY FOUNDATION
The National Kidney Foundation is an ideal
example of a grassroots patient advocacy organization
consisting of medical professionals, staff and
volunteers working together to attain their ultimate
goal "The Eradication of Diseases of the Kidney and
Urinary Tract". The following will present a brief
history of the development of the National Kidney
Foundation and its involvement in policy legislation
improving the life for the renal patient.
The National Kidney Foundation as we know it
today, began in the early 1950's, in the home of a
parent whose child was afflicted with renal disease.
The parents of children stricken with kidney disease
joined in an effort to improve the plight of those
with this dreaded fatal disease. The organization
began under the auspices of the National Nephrosis
Foundation which was concerned primarily with research
and education on children with nephrosis. Initially,
their efforts concentrated on issues such as public
education concerning nephrosis, increased research
funding, development of a medical advisory board
(physicians mainly specializing in pediatrics, but
other medical personnel as well) and setting goals and
49
objectives for the organization.
As time went on affiliates were formed in many
states, the organization broadened its scope to
include all aspects of kidney disease, and in 1958
officially became the National Kidney Disease
Foundation. Along with this growth came extended
education and involvement from medical and volunteer
individuals across the country. The early 1960's were
a time of a great deal of exposure and recognition for
nephrosis. In these years there was a campaign for
more research, training, education and prevention.
In 1964, the name of the organization was changed
one last time to the National Kidney Foundation. The
passage of the Medicare act in 1965 and the Anatomical
Gift Act (as described previously) were both major
pieces of legislation in which NKF played a major
role.
The increased involvement through congressional
circles was necessary to develop a firm political
voice and this was developed in the early 1970's.
The signing of H.R. 1 on July 1, 1972 by President
Richard M. Nixon (which was previously discussed) was
an event marking a significant part of NKF history.
Upon passage of this legislation, the need for
dialysis machines increased as those who were unable
to utilize the treatment previously were now able to
50
dialyze. The cost for these machines, additional
personnel, etc. was encompassed through ESRD. Since
the cost factor of supplying treatment to patients was
now accomplished, the NKF would be able to further its
pursuit in arenas of research and education.
The past ten years encompass many accomplishments
both within the organization and throughout the renal
disease community. The numbers of people receiving
dialysis and transplants has increased tremendously
(see Chapter III, Patient Population/Utilization) and
the numbers of afflicted patients and families able to
receive support through the Foundation has increased
nationwide. Such major events include many religious
organizations endorsing organ donation for their
membership; post-doctoral research fellowships working
on areas of causes, cures and prevention of renal
disease; endowed research funding to continue research
past the fellowship stage, etc. In 1983, a Gallup
poll was taken which indicated the success of the
Foundation in educating the public regarding organ
donation. The poll revealed that 24% of the adult
population were very likely to want to donate their
kidneys after death. The percentage of those
individuals who were likely to offer the organs of a
loved one after that person's death was 72% (Gallup,
1983) .
51
The National Kidney Foundation plays a major
advocacy role for the renal disease patient. They
have become a lobbying force in policy arenas and
their continued research in the fight to find a cure
for kidney disease revolves around their sincere
dedication to the patient. Therefore, it is apparent
that any form of rationing of services provided to the
elderly renal patient would be met with a firm stance
by the NKF which would use the statistics previously
presented to wage a battle for the patient's welfare.
The following chapter will focus on various rationing
ideas, an overview of the National Health Service in
Great Britain, and finally a proposal which suggests
rationing should be implemented towards the elderly.
52
VI. HEALTH CARE RATIONING
A. OVERVIEW OF RATIONING CONCEPTS
The mere mention of the term "rationing" in
association with health care is one which produces a
great deal of fear and controversy, especially among
professionals in the fields of gerontology and
geriatrics. Increasing health care costs and
expenditures for the elderly has become a major issue
on the agenda of many policy-makers and ethicists
across the country. Therefore, it is necessary to
address and examine the various issues involved with
the concept of rationing to gain a further
understanding of the topic under debate.
When analyzing health care costs it is advisable
to explore some of the relevant economic ideas which
influence decisions concerning the allocation of
resources. This is essential because a great deal of
the concern arises from strictly the dollar amounts
spent on the various programs without regard for the
ethical basis for their existence. Three fundamental
principles expressed by Fuchs (1973) are: 1) resources
are scarce relative to wants; 2) these resources have
alternate uses; and 3) people have different wants and
will assign different values to them. There is no
scientific method to determine the proportion of
53
resources a society should devote to medical care
(Mechanic, 1979). But, when it becomes too expensive
to meet all needs, then the designated allocation of
care must be determined by some principal. The amount
of rationing which is necessary depends on the
1)ability to produce needed services more
economically, or to develop functional substitutes; 2)
the effectiveness in decreasing the demand by either
preventing illness, limiting of the arena of
responsibility of medical care or changing the
consumers' desire and expectations for care ; and 3)
the level of resources which individuals and
government are willing to invest in medical care at
any time (Mechanic, 1979).
There are two general categories of rationing.
The first is termed, implicit rationing, which places
a great deal of emphasis on the system and the
physician. It requires the physician to allocate
resources based on enforced budget limitations.
Examples of implicit rationing are Great Britain's
National Health Service (which will be discussed in
the next section) and the health maintenance
organizations presently increasing in number
(Mechanic, 1979). In this type of rationing there are
specific guidelines for the physician to follow,
therefore, in some cases in the U.S. where a treatment
54
would be initiated, in Great Britain there would be no
choice and it would not be covered under the NHS.
The second type is referred to as explicit
rationing. This format transfers more of the
physicians responsibility of adhering to budget plans
to the administrative center. Decisions from
administration can affect areas such as limitations on
types and availability of certain visits and/or
procedures which are covered, exclusion or inclusion
in specific plans, etc. (Mechanic, 1979).
The type of rationing a system instigates appears
to be directly related to the amount of rationing
deemed necessary. The three factors expressed by
Mechanic indicate the basis for the reasoning
involved. For example, the ability for the U.S. to
change the consumers' desire or expectations to obtain
the highest quality of health care available would be
difficult. These are factors inherent in a system and
once established would be difficult to alter or
delinquish.
Cost is generally a primary factor leading a
system to consider an aspect of rationing medical
services. The ability to control spending in health
care can be difficult, but Fuchs (1986) offers three
approaches: 1) to improve the efficiency in allocation
and provision of services; 2) reduce cost for
55
materials and services utilized in medical care; and,
3) decrease the volume of service provision or shift
from high-cost to low-cost services.
The medical efficiency of a delivery system is an
area which deserves attention when decisions regarding
allocation of health care services arise. Aaron and
Scwartz define, "Medical resources are efficiently
used when a given total expenditure cannot be
reallocated to alternative kinds of care to achieve an
improved medical outcome" (Aaron and Schwartz, 1984).
Thus, the treatment given will result in the highest
degree possible in functioning, quality of life, etc.
for the individuals under treatment. The reduction in
price of materials and/or services would imply paying
the provider and/or producers less— which would not be
an easy concept to sell. The last approach indicated
by Fuchs designates a decrease in the services
provided or to obtain a lower-cost service. This is
likely to be perceived negatively in the U.S.,
especially in terms of its affect on quality of care.
Even though studies can suggest it is possible to
dramatically reduce medical spending without negative
ramifications on quality of care, the decrease would
be perceived as negative (Altman and Rodwin, 1988).
For example, if the type of dialysis machine used was
the top in the field, and the patient was told a
56
cheaper model would be used to save money, the patient
would tend to feel the cheaper model would not do as
well as the more expensive machine, therefore the
quality of care would be perceived as lower.
Another concept to address involving health care
expenditures and rationing are the costs and benefits
of the treatment both to the patient and to the
system. The aspect of medical efficiency of the
treatment plays a major role when evaluating the
costs/benefits. The factors weighed by a physician
when deliberating various treatment possibilities
should integrate the possible outcomes so that the
procedure chosen will be of the fullest benefit to the
patient. Of course, decisions concerning what is
beneficial to the patient will in certain cases result
in differing opinions (Aaron and Schwartz, 1984).
These differing viewpoints depend on individual
situations under scrutiny. For example, an elderly
individual who has advanced stages of cancer and
multiple other diseases suffers renal failure. The
decision to implement dialysis would not be an easy
decision for the individuals involved.
The increased frustration in the cost-containment
battle with health care costs has inclined some
individuals to examine analytical vehicles in studying
resource costs and allocation procedures. Quantitative
57
tools can be used very inappropriately and one must be
careful that the assumptions made do not produce
discrimination towards a specific sub-population, such
as the elderly who tend to be an available target
(Avorn, 1984). One of the most overt examples
involves the issue termed "human capital". This
approach basically assigns a dollar amount to the
human lives which could be saved or will perish. A
study by Dolan, Hodgson and Won (1980) described and
calculated human monetary values for both men and
women at various ages (See Table 8. Value of Life at
Various Ages). This exemplifies various ideas which
can occur when attempts are made to assign dollar
amounts to the value of a human life and imply
individuals are "worth" less as they get older.
Another quantitative form of analysis which again
places the young against the old in many cases is that
involving quality of life which was briefly discussed
in Chapter 2. Although this measure does not place a
dollar value on an individual's worth, it does attempt
to value the number of years which will be saved and
their potential worth. This type of analysis is
highly suspect because of the method used to derive
relative values for individuals quality of life. A
problem with this is that when questions are asked of
people, their responses can be potentially generalized
58
incorrectly and utilized in the policy arena as basis
for discussion on a particular issue. For example,
people were asked how many years of healthy life they
would trade for ten years involving a condition such
as end-stage renal disease (requiring dialysis) or
another chronic disease such as arthritis (Klarman,
Francis and Rosenthal, 19 68). Another study actually
expressed that the quality of life with a mastectomy
would only be worth one half of a year of a healthy
life, and life on dialysis worth one third of a normal
year (Sackett and Torrence, 1978). These studies
asked individuals to express quality of life values
based on their perceptions of how specific conditions
would compare to a healthy life. They stated that
once an individual endures specific conditions their
life is worth less than if they were healthy. Results
such as these should be viewed with great caution as
individuals questioned have not experienced the
specific conditions and is based on speculation as to
what the situation would be like.
These discussions are not to say that
quantitative methods of analysis do not have their
place in assessment measures involving some aspects
of the health care system, but that their use in
health care allocation must be used with extreme
caution.
59
B. GREAT BRITAIN - THE NATIONAL HEALTH SERVICE AND
RENAL DISEASE TREATMENT FOR THE ELDERLY
The National Health Service (NHS) was founded in
Great Britain forty years ago and has been considered
one of the world models of socialized medicine. NHS
is an interesting system for many analysts of health
services as well as to specialists in the fields of
geriatrics and gerontology. The ideas of rationing
will be integrated into the discussion of the NHS in
relation to the allocation of treatment to renal
disease patients. The NHS is an example of an
implicit rationing system. It is characterized by
fixed prospective budgets, a specific number of
specialists in designated regions, limitations on
available beds and regulations on allocation of
various life sustaining technologies including
dialysis and transplantation.
The example of renal dialysis is used by Klein
(1983) to demonstrate how Britain's central government
"could actually control the introduction of a new
technology without ever appearing to be infringing
medical autonomy". In the 1960's when the new
technology known as dialysis effectively demonstrated
the capability to save lives, but was expensive, in
great demand and widely implemented, the Ministry of
60
Health's hierarchy stepped into view. A series of
conferences were convened and the process of
engineering a professional consensus was under way.
In the outcome, medical agreement was obtained for
what was all but in name a strategy to ration scarce
resources; a policy which concentrated renal dialysis
facilities in a limited number of centers— a policy
which was justified, however, not by resource
constraints, per se, by medical consideration about
the desirability of concentrating expertise. Thus,
access to renal dialysis was limited. The criteria
which are used in evaluation of treatment are very
stringent and more severe than in many other countries
(Iglehart, 1984) . As Wing (1983), a British
nephrologist noted recently, Britain has only 1.1
dialysis and transplantation center per one million
population, as compared to 5.9 in Italy, 4.4 in the
Federal Republic of Germany, 4.3 in Spain and 3.7 in
France. There are even more centers noted in Eastern
European countries such as 3.0 in Yugoslavia and 2.8
in the German Democratic Republic. Along with the
lower number of centers, the treatment centers are
dispersed unevenly across Britain with more facilities
and access in specifically designated regions.
In Great Britain, the process by which demands
are placed upon the delivery system is extremely
61
complex and involves numerous non-medical decisions.
What surfaces is that demand tends to outweigh supply.
This limitation of medical services places the
physician in an awkward position which most find very
unpleasant. Neither the training nor the ethics of
the medical field prepares for the decisions based on
economics. Therefore, whenever it is possible, the
doctors in Great Britain will translate a problem of
scarce resources into medical terms. Essentially,
they have developed standards of care which
incorporate their economic reality of denying
treatment into proposed medical judgements (Aaron and
Schwartz, 1984).
The treatment procedures implemented in Great
Britain for renal disease patients put a great deal of
pressure on the physician. Physicians must often
refuse treatment to certain patients and an older
patient who is a candidate for kidney dialysis is a
good example. The financial limits which were
instigated discouraged physicians from treating those
patients over age 60 (Nicholls, 1980). Saying no to
any patient would be difficult, therefore often the
internist will either not raise the possibility of
dialysis or will simply express to the individual that
the treatment does not appear warranted. The doctor's
recommendations are usually adhered to with few
62
complaints due to the respect for the physician (Aaron
and Schwartz, 1984). Society has been traditionally
avoided the overt recognition that choices would have
to be made not to save lives because it was too
expensive. But, when such decisions become public
knowledge the society was astounded. As an example,
until very recently it was understood by the physician
community in Great Britain that those individuals over
the age of 55 with kidney disease would not be
referred for dialysis or transplantation. However, in
1984 this unwritten policy became highly visible.
Data were publicized which showed the incidence of new
cases of ESRD being treated in Great Britain was 40
per million (vs. 80 per million in the U.S.) which
resulted in approximately 1500-3000 "unnecessary
deaths" annually (Annas, 1985).
In 1977, the cost of dialysis (hemodialysis) in
Great Britain averaged $18,000 in hospital and $11,500
at home. The costs incurred for transplantation and
follow-up treatment for one year were similar to costs
incurred with home dialysis. In contrast to the U.S.
is almost two-thirds of dialysis is done at home in
Great Britain (Aaron and Schwartz, 1984).
Transplantation has become an accepted and successful
method of treatment for those affilleted with ESRD in
Great Britain also. The overall number of kidney
63
transplants has been rising since the late 1970's. In
1978 there were 94 kidney transplants and 1,334 in
1985 (Central Statistics, 1987). The numbers of new
kidney patients increased from 12 33 in 1979 to 202 3 in
1984. There were 11,235 patients receiving treatment
for ESRD on December 31, 1984; with half of this
number receiving transplants. Dialysis costs average
about $15,000/year. Transplants cost $8,000/year with
approximately 2,000/year afterwards for follow-up. As
in the U.S., there has been an increasing educational
program for organ donation. In 1986 in Great Britain,
the waiting list for a kidney transplant was
approximately 3,000 individuals, a number which
continues to rise due to improved techniques resulting
in higher referral rates (Central Statistics, 1987).
1. U.S. AND BRITAIN— DIFFERING PHILOSOPHIES ON
ALLOCATION OF SERVICES FOR ELDERLY RENAL
DISEASE PATIENTS
The most striking difference between British and
U.S. treatment for renal disease in the elderly is
that virtually every patient in the United States is
treated, whereas most in Britain are not. It is
accepted unwritten policy that individuals over 65
64
years of age should not be considered for dialysis
treatment. This is reflected in the data previously
presented indicating 1500-3 000 unnecessary deaths
occurred in 1984. This is evidenced by the number of
patients undergoing treatment. In the United Kingdom,
69 people per million were undergoing dialysis and 56
per million had functioning transplants in 1980. By
contrast, 230 people per million were undergoing
dialysis in the United States in 1980 and about 57
million are estimated to have functioning transplants.
Thus, the rate of the population undergoing dialysis
in the United States is three times larger than that
in the United Kingdom, yet the rate of functioning
transplants is almost identical (Aaron and Schwartz,
1984) .
If fewer cases of kidney failure are being
treated in Britain than the United States, who are
those not being treated and how are these decisions
being made? Age is clearly seen as a major factor.
Parsons states, "the tacitly agreed upon maximum age
for dialysis treatment rose from 45 in 1963 to 60 in
1978" (Parsons, 1978). The rate at which new patients
are accepted for treatment until the age of forty-four
is the same in Britain as France, West Germany, and
Italy. Among those patients who are between the ages
of forty-five and fifty-four the rate of treatment
65
noted in Great Britain is only about two-thirds that
of the three mentioned countries ; among patients who
are fifty-five through sixty-four, about one-third;
and among patients who are sixty-five and older, the
ratio is less than one-tenth (Aaron and Schwartz,
1984). It is important to note that over the past few
years the British delivery system for ESRD has come
under fierce attack, primarily by the British
patient's association, but also by nephrologists who
are responsible for patient care and unsatisfied with
the present system (U.S. Department of Health and
Human Services, 1987). There have been several
articles in the British Medical Journal, that reflect
this trend, notably including a report on the
successful treatment of those patients over the age of
65. Iglehart states,
"thus far, though, there is no general evidence
of change in the restricted availability of
dialysis treatment in Britain. The officials
at the Department of Health and Social Security
with whom I discussed this issue said
that any appreciable increase for renal disease
simply is not a priority at this time"
(Iglehart, 1984).
However, as the study by the Department of Health and
Human Services (1987) indicates through the words of
Diana Brahams, a British barrister who has examined
the "doctors duty and the patient's right" in the
treatment of end stage renal disease, there may be
66
changes in the future. The British Kidney Patient
Association (BKPA) estimates that between 2,000 and
3,000 deaths occur per year in Britain from renal
failure, many of which are unnecessary. The BKPA is
in the process of escalating its efforts in order to
attain increased availability of treatment for those
in need, and recently announced that the next patient
brought to their attention who is refused treatment by
NHS, will have the opportunity to be treated privately
at the Association's expense. However, the bills for
the various treatments will subsequently be presented
to the NHS; and in the event that they are not paid,
Braham's states (in Brahams, 1984) the BKPA, ..." is
prepared, apparently to take the Secretary of State to
court -presumably for failing to provide necessary
treatment required under the National Service Act, the
private hospital bills amounting in effect to damage".
There exists an underlying fear by many that
there is a remote possibility some version of the
British system may be adopted in the United States for
the treatment of elderly patients with ESRD. Although
it is not being considered by the Congress or HCFA at
present, there is growing concern that some form of
major change may be inevitable (Iglehart, 1984). This
indicates drastic financial implications for many
individuals with ESRD leaves a large number of poor
67
elderly who will not be able to afford the private
costs. It is interesting to note the increase of
private insurance organizations which are becoming
estabished in Great Britain, and are encouraged to do
so by the NHS. This offers more treatment for
patients, with the expense consumed by sources other
than the NHS. For example, in 1971 there were 87,000
private out-patient attendances in NHS hospitals
whereas in 1985 there were 240,000. The public
expenditures on NHS have increased nearly 48% in the
past five years therefore the need has arisen to turn
to the private sector for further funding of health
services (Central Statistics, 1987).
It is obvious from the previous discusion that
differing values exist in the U.S. and Great Britain
regarding the allocation of health care expenditures
for renal disease treatment in the elderly. The
aspect of utilizing age as a criterion for allocation
of life sustaining technologies in the elderly has
been developed into a proposal for the United States
to consider. The following section will briefly
address this specific philosophy regarding health care
rationing and discuss the potential impact on the
elderly renal disease population.
68
C. A RECENT RATIONING PROPOSAL-BY DANTET. CAT.TAHAN
An 87 year old man, in generally good health,
suffers kidney failure due to a severe flu virus.
Should he be put on kidney dialysis, or should he be
considered for a kidney transplant? He should not
receive either of the life-sustaining treatments
believes Daniel Callahan, noted medical ethicist and
Director of the Hastings Center, a noteworthy
thinktank in New York. Callahan has proposed the
rationing of life-sustaining technologies for the
elderly as the only feasible avenue to slowing down
the increasing health care costs covered by Medicare
(Callahan, 1987).
The premise for Callahan's proposal is the use of
age as the major criteria in rationing health care to
reduce federal expenditures. The use of the term
"rationing" for Callahan refers to limiting, or
denying all life-sustaining technologies to the
elderly. This includes a spectrum of technologies from
administration of antibiotics for pneumonia to
dialysis for renal failure. Callahan does not give a
specific age at which to implement his philosophy, but
uses the range of approximately 65 to early 70's in
his decision. Callahan discusses his rationale for
limiting resources within his philosophy of
"wholeness of a human life". He illustrates this by
69
describing situations in which an individual body is
in a state of "wholeness". Not the case when the
person's life holds little meaning or significance to
them; or, the instance when a person's body loses its
"wholeness" prior to the time the person was able to
live out a full life (otherwise known as a premature
death). He develops this issue into the concept of a
"natural life span" and a "tolerable death". The
natural life span is a span of life in which the
desired life accomplishments have been achieved and
although death would be a sad experience, it would
essentially be acceptable (again, Callahan maintains
that most should have lived a natural life span by age
65, and definitely by the late seventies or early
eighties). Therefore, Callahan believes a tolerable
death should occur upon the completion of the natural
life span (Callahan, 1987).
Callahan believes that medicine should be more
oriented towards relief of suffering and not continue
its crusade against death and decline. Callahan would
like to ensure that elderly can live out their years
with vitality and be contributing forces to society
and examples for generations to follow. This should
help the elderly realize their "stage in life", which
is not considered to be dependent on physical
astuteness or economical productivity. He notes the
70
hospice philosophy has guided us in a more feasible
way of differentiating "relief of suffering and
prolongation of life". A minimal goal would be for
the elderly to possess more control over their own
death, especially their right to refuse life
sustaining technology. Callahan exerts this to be in
direct relation to rising health care costs,
the indefinite extension of life combined with an
insatiable ambition to improve health of the
elderly is a recipe for monomania and bottomless
spending. It fails to put health in its
proper place as only one among many human goods.
It fails to accept aging and death as part of
the human condition. It fails to present to
younger generations a model of wise stewardship
(Callahan, 1987).
A major thrust of Callahan's proposal integrates
the issues of costs with the issue of
intergenerational equity. Intergenerational equity
involves the relative distribution of services between
the elderly and children in the United States. He
feels that expenditures are presently being spent on
the elderly, at the expense of children. This
controversy is furthering the issue which surfaced
when former Colorado Governor Lamm stated the ill
elderly have "a duty to die and get out of the way".
Callahan states the
government can not be expected to bear, without
restraint, the growing social and economic costs
of health care for the elderly. It must draw
lines, because technological advances
71
almost guarantee escalating and unlimited costs
which can not be met, and because in any case,
it has a responsibility to other age groups and
social needs, not just to the welfare of the
elderly (Callahan, 1987).
The foundation of Callahan's argument lies on
rationing of services to the elderly to ensure
resources for future generations. Callahan utilizes
these arguments to discuss allocating health care
services and cost in relation to the elderly. He
expresses since those who have reached the age of 65
should definitely have lived a full life, a tolerable
death ensues. With this reasoning, it should prove
acceptable in society not to allow life sustaining
technologies to those over a specific age. Therefore,
he believes the elderly are not entitled to coverage
such as Medicare and should not expect it. He further
exemplifies these bold feelings by saying,
"Look, we have already done justice to you in our
society by getting you this far. And, we cannot be
asked to indefinitely extend your life" (Callahan,
1987). He notes that the rising costs incurred by
Medicare are due mainly to chronic diseases in the
elderly, and that these needs are currently not being
met through the government in such areas as long term
care, etc. But, he feels we need to limit our
expenditures on the elderly in order to ensure our
country for our future generations. Callahan
72
indicates his criteria for what he believes to be
criteria "morally appropriate treatment" and these
include three major considerations : 1) the physical
and mental status of the patient; 2) the levels of
possible medical and nursing care; and 3) the quality
of life of the patient (See Table 9. Classifications
for Morally Appropriate Care).
Callahan also proposes three principles which
reinforce his request for limits to be enforced.
First, government has a duty, based on our
collective social obligations, to help people
live out a natural life span but not to help
medically extend life beyond that point.
Second, government is obliged to develop under
its research subsidies, and to pay for under its
entitlement programs, only the kind and degree
of life-extending technology necessary for
medicine to achieve and service the aim of the
natural life span. Third, beyond the point of a
natural life span, government should provide
only the means necessary for the relief of
suffering, not those for life-extending
technology (Callahan, 1987).
2. THE IMPACT ON ELDERLY RENAL DISEASE PATIENTS
Callahan expresses with firm conviction his
feelings towards higher medical technology in relation
to extending the lives of the older population. He
expresses,
"... no technology should be developed or
applied to the elderly that does not
promise great and inexpensive
improvement in the quality of their lives, no
matter how promising for life extension.
Incremental gains, achieved at high cost,
73
should be considered unacceptable. Forthright
government declarations that Medicare
reimbursement will not be available for
technologies that do not achieve a high,
very high, standard of efficacy would discourage
development of marginally beneficial items"
(Callahan, 1987).
Kidney dialysis and transplantation would suffer
severe ramifications by a proposal for life sustaining
technologies for the elderly such as Callahan's. He
demonstrates his feelings about using dialysis by
insisting that,
"... dialysis represents precisely the kind of
technology that should not be sought or
developed in the future. It does not greatly
increase the life expectancy of its users
and for most, that gain is at the price of a
doubtful or poor quality of life and an
inability to achieve earlier levels of
functioning" (Callahan, 1987).
However, it is interesting to note an instance in
which Callahan accepts the use of dialysis. In his
discussion on "morally appropriate care" he states
for patients with mild competency impairments, that a
"grandfather clause would also be needed in some
circumstances; life extending treatment such as
insulin for diabetics or dialysis, if begun in early
old age, should not be withdrawn in later old age"
(Callahan, 1987). He also believes that
transplantation in the elderly is done at the expense
of children and should not be considered a viable
74
treatment for the elderly.
3. DISCUSSION OF CALLAHAN'S PROPOSAL
Daniel Callahan has used age as the criterion
upon which to deny life sustaining technologies. The
cut-off age at which technologies should be offered in
relation to living a "full life" appear to be
ambiguous. It would be a step backwards to use an age
criterion for care in both the medical and ethical
schools of thought. The medical field has produced
amazing sources of treatment strategies to sustain and
extend life and to increase treatment for various
diseases. It would appear feasible to suggest medical
science continue to improve their treatment of, and
possible cure for, many of the chronic disease
afflicting the elderly today. Callahan's proposal has
the possibility of back-firing in reference to costs,
especially in terms of long term care. For example,
if a hip replacement is denied there is a good
possibility that extensive long term care services
would be utilized and disability and dependency arises
for the patient (Schneider, 1988). It should be noted
each situation merits evaluation upon an individual
basis as to the costs/benefits of various treatment
modalities. But, in Callahan's proposal, there is no
choice to be made, it has been made for the patient
75
once they have lived past the age of 65 years. The
advances made involving the physician, family and
patient in the decision for treatment possibilités
would no longer hold true. Butler (1975) describes
various forms of stereotyping and prejudice against
the old, and is known as "ageism". It implies the
elderly's value and contributions to society are of
less significance when compared to other age groups.
Callahan makes a distinct comparison between the
elderly and the younger generations, decreasing the
elderly's worth.
It seems unlikely that our society would accept
the argument that elderly should suffer because the
government is not able to curtail health care
expenditures. In a political sense, it does not
appear feasible that a politician would sacrifice his
reputation and future attempting to curb expenditures
on health care for the elderly, especially since this
group has developed substantial lobbying power in
political arenas. However, there are groups such as
Americans for Generational Equity (AGE) who continue
this intergenerational discussion and place further
barriers between the generations regarding federal
expenditures. They believe if government
dispursements of dollars to the elderly decreased,
then indeed those monies would go to children. This
76
deduction is difficult to believe when one evaluates
the entire federal budget and reasoning in allocation
of funds. One may wish to assess various health care
expenditures when conducting an analysis to determine
beneficial forms of treatment. Kidney dialysis and
transplantation have demonstrated benefits to elderly
in survival rates and quality of life. Great amounts
of money are spent on various procedures (for all
ages) for cancer, neonatal, etc. which provide
minimal benfefits in survival or quality of life.
Callahan's proposal encompasses many ethically
based issues in his discussion of denying life
sustaining technologies to elderly in the United
States. He views the elderly as a population
utilizing services which they should not be entitled
to obtain. This reasoning contradicts the basic
concepts involved in advanced medical research in
order to save or extend lives. An aspect which
warrants caution is that he is not just analyzing
beliefs and cost expenditures— Callahan believes and
wishes policy to be implemented and enforced. This is
a dramatic proposal and one which would require a
restructuring of our value system regarding the
elderly and medical technology.
77
VII. IMPLICATIONS/PROJECTIONS FOR THE FUTURE IN
RENAL DISEASE
It has been shown by data, statistics and ethics
in this thesis that dialysis and transplantation are
effective and beneficial treatment modalities to
elderly patients afflicted with renal disease. The
notion of limiting procedures on the basis of age such
as Callahan's proposal, appears not to warrant
discontinuing these treatments.
The economic status of the federal budget and the
growing deficit over the last eight years have
resulted in panic by a number of people to look for
ways of alleviating a portion of this burden.
However, to propose cut-backs in life-sustaining
technologies for the elderly such as Callahan has done
as a feasible avenue in this endeavor is not
appropriate.
It has been evidenced that the population of the
elderly segment of our country is increasing at a
phenomenal rate, with the largest increase in those of
the 85+ sub-group. Therefore, not only a concentrated
effort is needed in furthering our knowledge and
expertise in treatment procedures for these
individuals, but also that we maintain the ethical
standards on which our system was established. Thus,
78
the utilization of rationing proposals involving areas
of determining one's worth or value based on age, are
examples which should be approached with great caution
and demand firm statistical data to confirm the
assumptions.
The increase in the general population of elderly,
is also shown in the older population under the ESRD
program. The projections for the future utilization
of the program by the elderly is indicated by the past
growth from 1967 to 1978. It appears a focus is
needed on the group of patients who are 55+. This
group covers a large age range. It would be
interesting to have a break-down by ten year intervals
to clarify the age utilization by the older segments.
It is evident that if this group is already utilizing
the program, there is a distinct possibility it will
continue on until the late years in life. Of course,
this depends on the type of treatment received and
individual relative life expectancy. Another group
which deserves attention is the visible and
significant population of the baby boom era. This
group could apparently have a tremendous impact on the
health care system of the U.S. if adequate planning is
not implemented.
There are some disturbing complications which
could occur in relation to issues of health care
79
rationing with the elderly. It appears that there
could be a decrease in the value placed on the elderly
and their importance to our society. Aspects of
passive euthanasia, or just giving up on life could
escalate, especially as Callahan emphasized the
patient's right to end his/her life. However, a
positive effect of the introduction of these issues
could be that more individuals are becoming aware of
documents such as living wills, etc. These ensure that
if an individual is in a medical situation in which
he/she is unable to make a competent decision, his/her
wishes will be implemented as directed by a legal
document which was previously developed.
A reoccuring issue in Callahan's proposal
involves intergenerational equity, the act of pitting
children against the elderly regarding the allocation
of health care. This produces unnecessary dissension
and unrest. There may be other areas which deserve
attention and evaluation of the future resources for
our children (ie: Social Security), but should not
produce intergenerational warfare in the process.
These issues cause caution in the political arena and
warrant serious consideration in approaching
solutions.
Issues to address when looking to the future
include the comparison of dialysis and transplantation
80
as viable options for treatment, and how they may or
may not change in the future in relation to older
patients It is necessary once again to emphasize how
treatment is very individualized. The continued
involvement of the patient, physician, and the family
in the treatment decision is vital not only at
present, but will be in the future as well. As Dr.
Thomas Peters, Professor of Surgery, University of
Tennessee states, "Evaluating the newer developments
involves remembering our history, envisioning the
future possibilities, and carefully analyzing the
bioethical issues. Additionally, in assessment of
emerging techniques, the patients and families must
not be forgotten" (Peters, 1987).
There are situations where treatment may not be
warranted due to the health state of the individual
patient or their own choice in denial of treatment.
These are difficult decisions which physicians,
families and patients face. This leads to the quality
of life concept which requires further research and
refinement in its measurement to more accurately
define outcomes of treatment. A complicating issue
included in this arena involves the factor of who is
viewing and issuing the assessment of an individual's
quality of life; is it the physician, patient, or
family? Quality of life is a relative and somewhat
81
intangible measure which requires great caution in its
utilization for treatment determination. As Christine
Cassell has stated, "One person wants comfort and help
in confronting pain and frailty and another is more
interested in pride and independence than in treatment
of swollen ankles" (Cassell, 1986). Thus, there is a
continued need for the patient to be a major player in
the treatment decision which will best suit his/her
lifestyle and situation. In the treatment decision
process in the British health care system, the elderly
renal disease patient does not receive a choice in
their treatment regimen. Unless they can afford
private insurance, they will eventually die.
The treatment determination of dialysis vs.
transplantation involves the availability of organ
donars. The increased movement to encourage
individuals to donate their organs or a loved one's
upon their death appears to require continued efforts.
The choices that are made usually relate to the
availability of organs for those needing transplants
and weighing the risks/benefits in each case. Cost is
argued as a positive factor in considering
transplantation because it is a more cost effective
mode of treatment than dialysis. Cost is generally a
major factor in evaluation of program effectiveness.
In an interesting study by Kilner he obtained
82
information through questionnaires of U.S. Medical
Directors of Kidney Dialysis and Transplant
Facilities. He analyzed a number of selection criteria
which are currently used and asked what would change
if resources would become scarce. The criterion of age
is employed in 10% of dialysis facilities today, but
85% would employ age under conditions of scarce
resources. Kilner states.
Significant medical problems are already taken
into account by a medical-benefit criterion,
though, so an age criterion per se may well
reflect the low value placed upon the
elderly in U.S. society (Kilner, 1988).
Through this data it appears increased education and
training of physicians (and other health care
professionals) is necessary in geriatric nephrology
issues to increase their knowledge base and expertise
to ensure effective diagnosis and treatment for
elderly renal patients.
One interesting factor to note in relation to
transplantation is the process which a patient goes
through in order to obtain a transplant. The
nephrologist must determine whether a patient is an
optimal candidate for a transplant, if so, he/she is
referred to a transplant surgeon. If not, he/she is
on some form of dialysis. However, there are some
physicians who do not refer patients because of the
due financial incentives of having them on dialysis or
83
because of age bias.
Another area of focus in which increased numbers
of physicians are becoming aware involves the
psychological adaptation of the patient following the
transplant procedure. After the transplant operation
the surgeon's interaction with the patient usually
continues to diminish. There are very few trained
individuals to adequately counsel patients how to
adapt to their new lifestyle, return back to work,
etc. This seems to be an area which would merit
sufficient attention. It appears detrimental to give
a person a life which is free of treatment
complications associated with renal failure through
transplantation if they may be unable to adapt
adequately to the change.
The future holds extreme promise for those
currently afflicted with ESRD, no matter what their
age. In the past when kidneys failed one had very few
alternatives from which to choose. It appears logical
to concentrate major research monies on finding a cure
for kidney disease. Fortunately, there are dedicated
individuals continuing to strive to provide a better
life for those afflicted with kidney disease. The
following section will give us insight from a select
group of physicians who have dedicated their lives to
kidney disease issues and patients.
84
A. VIEWS FROM RENAL DISEASE EXPERTS
As we are faced with ethical issues as this
thesis involves, it is necessary to gain further
information and insight from experts in the field who
work with these emotional situations on a daily basis.
Various issues previously discussed involving dialysis
and transplant procedures in the elderly are worth
repeating in order to incorporate viewpoints from
noted experts in the field of renal disease.
The physicians interviewed are prominent in the
field of kidney disease and graciously offered their
time to disclose their opinions and expertise in an
effort to obtain a clearer perspective on the issues
researched. The following are summaries of their
opinions on certain issues with some additional
personal views on specific issues they felt to be
re1event and beneficial.
A general consensus of all physicians was that
evaluating patients for treatment was always an
individualized decision process. Items noted as
relevant in the evaluation process included weighing
the risks/benefits for the patient, considering life
expectancy (in absense of renal disease), general
ability to adapt to treatment, presence of extra-renal
disease, rehabilitation potential, and view of their
85
own lifestyle. It was interesting to note the age of
55 years was not considered "elderly" by any of the
physicians. They considered "elderly" nearer the age
of approximately 70-75 years.
The decision to not initiate treatment of any
kind occurs very rarely. Most individuals in the U.S.
have the opportunity to receive treatment of one type
or another, whether it is dialysis or transplantation.
However, it is always possible a situation can surface
in which the coordinated team of physician, family and
patient determine that treatment is not warranted. "No
treatment is usually not a valid option unless the
patient is totally disabled by something other than
his renal disease" (Peters, 1988). A patient's age is
considered in the process, but is not a deciding
factor prior to thorough examinination and evaluation.
However, it was also noted that to die of renal
failure should not be considered an unpleasant and
painful death. The individual usually just goes to
sleep, therefore if one decides to withold treatment
they are relatively assured the patient will not
suffer from pain in renal failure with the ensuing
death process.
It was believed there would be an increase in
kidney transplantation in the upcoming years. The
factors of further research (better drug usage), less
86
expense, less cumbersome to the patient, etc. would
all be considered as positive perspectives for kidney
transplantation (Glassock, 1988).
In viewing the British NHS and their treatment
delivery for elderly renal patients offered similar
responses. It was noted that physicians have to
accept the process, but do not like having to withold
treatment. The increase in private insurance was
viewed positively for both patient and physician,
except for those elderly unable to afford the
services.
When questioned regarding Callahan's proposal on
rationing life sustaining technologies to the elderly,
responses were very adament and generally similar. It
was felt that the American people would not tolerate
the notion of witholding medical treatment for the
elderly in an effort to cut health care expenditures.
The issue of health care for Americans is viewed as a
right not a privilege.
It is believed transplantation was a good example
of cost containment over dialysis, for any age group,
including the elderly. "If rationing of health care
services for the purpose of cost containment is
desirable, then it makes sense to cut expenditures for
those patients, those conditions or those treatments
where the least benefit is obtained" (Glass, 1988).
87
Some of these include examples of cancers or neonatal
birth defects in which there is almost never a cure
and where health care expenditures exhibit little or
no demonstrable benefit. But, as Glass further
articulates,
"... as long as effective treatments are
available, an "elderly" person has as much right
as anyone else not to be debilitated by a
treatable kidney disease. Witholding such
treatment from patients, "elderly" or otherwise,
for the sole purpose of cost containment is
wrong" (Glass, 1988).
A viewpoint expressed by Schrier in reference to
Callahan's proposal states,
"...that an individual, society or nation must
establish moral and ethical standards upon which
their character is built. Then one can discuss
cost containment, military spending and other
issues. In medicine the patients
autonomy, well-being and physician-patient
relationship establish this foundation for
evaluation of questions such as are raised in
this thesis" (Schrier, 1988).
There was overwhelming unanimous response when
asked for future needs or trends in the arena of
renal disease. Prevention of kidney diseases was the
predominantly leading answer by all physicians
questioned along with further extensive research
endeavors. Dr. Glass (1988) included a few more areas
of interest including understanding and control of
allograft rejection and rehabilitation of dialysis and
transplant patients.
88
1. CASE STUDY
The following is a brief case study offered by
one of the physicians as an example of the increasing
avenues which are possible in treatment. And, after
the review of the past treatment procedures, the
tremendous advances of the past 20 years are apparent
in this case study.
The individual is a 76 year old man who was on
hemodialysis. The treatments were hindering his
lifestyle to a significant degree and he wanted
further evaluation. He was an active jogger and was
experiencing exhaustion at an earlier point than he
desired during exercise due to the rigor of dialysis.
Therefore, consultation between the family, physician
and patient was initiated to determine the feasibility
of a kidney transplant. Upon appropriate testing and
evaluation, it was found that his 18 year old daughter
was a suitable match as donor. After counseling and
further testing, the transplant was conducted and
remains to date a success. Although the use of the 18
year old's kidney was a risk in the eyes of the
physician, it was viewed as acceptable and feasible to
all those involved. (Of course, if there was an
abundance of donor organs available this dilemma of
taking a younger person's kidney would not have been
an issue if a match was found) The importance is
89
revealed once again for a close relationship between
the physician, family and patient to determine the
treatment modality which best suits the patient.
90
VIII. CONCLUSION
The issues raised in this thesis involve many
items of moral and ethical controversy which are
integrated in the topic of health care rationing, in
particular, focusing on the elderly renal disease
patients. A great deal of descriptive, statistical,
and expert information has been offered which
demonstrates substantial evidence to invalidate any
notion that it would prove feasible or acceptable to
ration dialysis or transplantation to the elderly in
the United States.
In the past 2 0 years the renal disease field has
exhibited tremendous strides in research and
development to assisting those afflicted with ESRD.
These entail the use of primitive shunts for
hemodialysis to continued research in improving
technology of all forms of dialysis. The increase in
kidney transplant procedures and availability of
kidneys through the education of the public for needy
individuals has proved a crucial aspect for the future
of renal patients. This accomplishment was prefaced
by hard work and the continued dedication by lay
people and professionals predominantly affiliated with
the NKF. The cost of treatment is unquestionably
expensive and there appears no change in the future.
91
However, as Caplan noted, when the ESRD program was
initiated, there was not ample allowance for changes
in the population or technologies, therefore
warranting an evaluation of the past fifteen years of
the program (Caplan, 1981).
The survival rates and various outcomes reveal
the improvement in technology and advances made for
all age groups afflicted with ESRD. It has been shown
through the survival rates for those over 55 that
dialysis and transplantation are beneficial and
successful forms of treatment for ESRD in this age
group. The study which demonstrated the increase of
graft survival with age is a definite indication of
the success transplants can have in the elderly. Data
and research are extremely valuable as there will be a
tremendous increase in the elderly segment of our
population over the next forty years. The British
population of elderly is growing as is the U.S.,
therefore the numbers of potential renal patients in
Great Britain are also increasing. When analyzing the
survival rates of renal disease patients in GB it is
evident that a large number of people over 65 die
because they are unable to pay privately for treatment
not provided by the government. Advocacy groups in
Great Britain are beginning to take a stance and
hopefully will have an impact on the allocation of the
92
health care dollar similar to that successfully
accomplished in the U.S. They are encouraging private
insurance coverage in assisting their public program.
However, this excludes individuals who are unable to
pay for the expensive coverage. The British system
does not appear to offer the U.S. a sound and stable
model exhibiting control of health care expenditures
in the renal area.
The issues involved in rationing health care in
the U.S. raise numerous concerns. There are various
economic ideas one could apply in attempting to verify
expenditures on countless procedures in health care.
However, as discussed the assumptions in which such
analyses are based mean that caution should be used in
applying them. The rationing proposal by Callahan
draws individuals from many professions to the
defense. His assumption that discontinuing life
sustaining technologies for people over approximately
70 years of age would cut the health care expenditures
has no firm foundation. He is apparently discrediting
the value of elderly who have lived beyond a specific
age. This appears to be a firm example of ageism, and
can only prove to increase barriers between
generations. His proposal has been met with
considerable controversy and debate. It goes against
the moral reasoning behind our health care delivery
93
system in the United States and does not appear to
merit consideration.
This thesis has examined the tremendous advances
made in the various areas involved with renal disease
from technological developments to crucial
legislation. Treatments of dialysis and
transplantation have been shown to be effective and
beneficial to elderly patients, therefore the attempt
to ration this mode of life sustaining technology
would be a very difficult task to accomplish. The
dedication of professionals in the field of kidney
disease research striving for a cure and additional
preventive measures give patients of all ages,
families, and physicians a great deal of hope for the
future.
94
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Effect of Age on Creatinine Clearance in Man: A Cross
Sectional and Longitudinal Study" Journal of
Gerontoloav 31:155-163, 1976.
Sackett, D.L., and Torrence, G.W. "The Utility of
Different Health States as Perceived by the General
Public" J Chron Dis 31: 697-704, 1978.
Schneider, E.L. "Assessing the Options for Responding
to Rising Health Care Costs of Older Americans" JAMA. j
(in press), 1988. I
Schrier, R. -as per personal interview and letter. !
Sourander, L.B. and Rowe, J.W. "The Genitourinary |
System-the Aging Kidney" In J.C. Bracklehurst (Ed.) |
Textbook of Geriatric Medicine and Gerontoloav, pp. '
608-625, Churchill Livingstone, 1985.
Stacy, W. and Sica, D. "Dialysis of the Elderly
Patient" In E. Zawada and D. Sica (Eds.) Geriatric |
Nephroloav and Uroloav. pp. 229-251, PBG Publ, 1985. i
99
Terasaki, P.I. "The Second Histocompatability Locus
in Humans" Transplantation Proceedings. Vol. XX, No.
1, Supp. 1, pp. 21-25, February, 1988.
Tenchkhoff, H. and W. Schechter "A Bacteriologically
Safe Peritoneal Access Device" Trans Am Soc Artif
Intern Organs 14: 181-86, 1968.
U.S. Department of Health and Human Services, Bureau
of Data Management and Strategy, Office of Statistics
and Management, division of Information Analysis, ESRD
Systems Branch, End Stage Renal Disease Patient
Profile Tables, Baltimore, MD, 1985.
U.S. Department of Health and Human Services, Health
Care Financing Administration, Office of Research and
Demonstrations, "A Special Report- Findings from the
National Kidney Dialysis and Transplantation Study",
Pub. No. 03230, October 1987.
U.S. Department of Health and Human Services, Aging
America-Trends and Projections U.S. Senate Special
Committee on Aging in conjunction with the American
Association of Retired Persons, Federal Council on
Aging, Administration on Aging, 1987-88.
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U.S. Department of Health, Education and Welfare.
Public Health Service, National Vital Statistics
Division, Vol. 2, part A, 1963.
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"Long-term Hemodialysis for Patients Over 50"
Geriatrics, pp. 55-61, Sept, 1976.
Wing, A.J. "Why Don't the British Treat More Patients
with Kidney Disease?" British Medical Journal
287:1157-1158, 1983.
Wood, R.F. Renal Transplantation: A Clinical Handbook
Eastbourne, England Balliere Tindall, 1983.
100
TABLE 1. WARNING SIGNS OF KIDNEY DISEASE
1. Burning or difficulty during urination.
2. More frequent urination particularly at night.
3. Passage of bloody appearing urine.
4. Puffiness around eyes, swelling of hands and
feet, especially on children.
5. Pain in small of back just below the ribs.
6. High blood pressure.
Source: National Kidney Foundation, Your Kidneys and
How to Detect Kidney Disease. New York, NY, 1980.
101
TABLE 2.
DIAGNOSTIC PROBLEMS OF RENAL DISEASE IN THE AGED
1. The unspecifiable nature of the symptoms and often
even the complete absence of the classical symptoms
associated with younger patients.
2. The concomitant occurrence of diseases other than
renal; diabetes, cardiac failure, arteriosclerotic
vascular disease— confuse both the clinical picture
and the symptomatology, and as a result the clinical
diagnosis often overlooks renal disease.
3. The interpretation of clinical findings, such as
the urinary findings and clearance estimations, is
often difficult without special knowledge of
alterations induced by the aging process.
Source: Sourander, L.B. and Rowe, J.W. "The
Genitourinary System-the Aging Kidney" In J.C.
Bracklehurst (Ed.) Textbook of Geriatric Medicine and
Gerontolocrv. pp. 608-625, Churchill Livingstone, 1985.
102
TABLE 3. PREVENTION OF ACUTE RENAL FAILURE
Maintain adequate extracellular fluid volume,
especially before surgical procedures.
Exercise caution with the nephrotoxic agents such as
the following:
Radiocontrast agents
Aminoglycoside antibiotics
Nonsteroidal anti-inflammatory agents
Certain cytotoxic agents (ie: cis-platinum)
If oliguria is present, rule out the presence of
prerenal azotemia and urinary tract obstruction.
Source: Feinstein,E. "Renal Disease in the Elderly"
In I. Rossman (Ed.) Clinical Geriatrics, pgs. 215-229,
Third Edition, Lippincott, 1986.
103
TABLE 4. NONDIALYTIC MANAGEMENT
OF CHRONIC RENAL FAILURE
1. Control of hypertension
2. Relief of urinary tract obstruction
3. Treatment of urinary tract infection
4. Dietary
a. Protein restriction with glomerular filtration
rate below 25 ml/min
b. Potassium restriction usually with glomerular
filtration
rate below 10 ml/min
c. Salt restriction usually not required until
advanced CRF
5. Medications
a. Aluminum hydroxide to bind phosphate in the
intestine
b. Shohl's solution to treat acidosis
c. Vitamin D (1,25-dihydroxycholecalciferol) to
treat
Vitamin D deficiency and hypocalcemia
Source: Feinstein, E. "Renal Disease in the Elderly"
In I. Rossman (Ed.) Clinical Geriatrics. Third
Edition, Lippincott, 1986.
104
TABLE 5.
ASSESSMENT INFORMATION TO OBTAIN FROM
TRANSPLANTATION CANDIDATE
1. The Cardiovascular system: Check for features of
cardiac failure and symptoms such as angina and
intermittent claudication.
2. Urino-genital system: Establish whether the
patient has had a history of urinary tract infection
and detail any difficulties experienced with
micturition.
3. Alimentary system: Inquire about symptoms of
gastrointestinal disorders that might be a problem
after transplantation, in particular, features
suggestive to peptic ulceration, hiatus hernia,
gallbladder disease, or diverticular disease.
4. Previous infections: It is important to find out
which infective problems the patient has experienced
and, especially, whether a patient has had
tuberculosis or has been in contact with close family
members who have suffered from the disease. In
patients who have been on peritoneal dialysis,
incidence of peritonitis should be recorded.
5. Previous surgery: Previous operations should be
recorded from the patient's notes, with a detailed
description of any urological procedures. It should
also be established whether any anesthetic problems
have been encountered at any time.
6. Family history: Relevant aspects of family
history should be investigated, with the state of
health of siblings being of particular importance.
7. Current therapy: Details of current therapy
should be listed, with an indication of how long the
patient has been on treatment for conditions such as
hypertension and whether the dosages of drugs have had
to be increased to maintain a stable blood pressure.
8. Blood transfusion: A detailed transfusion history
should be obtained, using case notes, any additional
information from the blood bank, and careful
questioning of the patient.
Source: Wood, R.F. Renal Transplantation: A Clinical
Handbook. Eastbourne, England Balliere Tindall, 1983.
105
TABLE 6.
CLASSIC CHARACTERISTICS OF REJECTION
1. Oliguria
2. Enlargement and tenderness of graft
3. Malaise
4. Fever
5. Leukocytosis
6. Hypertension
Weight Gain
Peripheral Edema
Source: Baquero, A. and Goldman, M. "Renal
Transplantation in the Elderly", In Geriatric
Neohrologv and Uroloav. 1985.
106
TABLE 7.
MEDICARE ESRD PROGRAM ENROLLMENT BY AGE, 1979-84
Age 1979 1980 1981 1982 1983
Under
25-44
45-64
654-
25 4,145
15,325
23,561
11,397
4,552
17,108
26,351
13,888
5,023
19,745
29,844
15,823
5,406
21,694
32,773
18,013
5,817
24,070
35,330
21,282
Total 54,428 61,899 70,435 77,886 86,499
Age 1984
Average annual
Percent Increase
1983-84
PercentIncrease
Under
25-44
45-64
654-
25 6,025
26,070
36,991
23,684
7.8
11.2
9.4
15.8
3.6
8.3
4.7
11.3
Total 92,770 11. 3 7.2
Source: Office of Technology Assessment, Life
Sustaining Technologies and the Elderlv. OTA-BA-3 06
Washington, D.C.: U.S. Government Printing Office,
July 1987.
107
TABLE 8.
VALUE OF LIFE AT VARIOUS AGES
AGE MALE FEMALE
30-34 $205,062 $130,044
50-54 124,989 86,286
70-74 9,781 29,189
85+ 943 5,705
— Values are expressed in 1977 dollars—
Source: Dolan, T.J., Hodgson, T.A., and Wun, W.
"Present Values of Expected Lifetime Earnings and
Housekeeping Services" National Center for Health
Statistics, Hyattsville, MD, 1980.
108
TABLE 9.
CLASSIFICATIONS FOR DETERMINING MORALLY APPROPRIATE
TREATMENT
1. PHYSICAL AND MENTAL STATUS
-PATIENTS WITH BRAIN DEATH
-PATIENTS IN PERSISTENT VEGETATIVE STATE
-PATIENTS WHO ARE SEVERELY DEMENTED
-PATIENTS WITH MILD TO MODERATE IMPAIRMENT OF
COMPETENCE
(OR FLUCTUATING COMPETENCE)
-SEVERELY ILL, MENTALLY ALERT PATIENTS
-PHYSICALLY FRAIL, BUT NOT SEVERELY ILL, MENTALLY
ALERT PATIENTS
-PHYSICALLY VIGOROUS, MENTALLY ALERT PATIENTS
2. LEVELS OF CARE
-EMERGENCY LIFESAVING INTERVENTIONS (EXAMPLE; CPR)
-INTENSIVE CARE AND ADVANCED LIFE SUPPORT (EXAMPLES,
INTENSIVE-
CARE UNITS, RESPIRATORS)
-GENERAL MEDICAL CARE (EXAMPLES, ANTIBIOTICS, SURGERY,
CANCER
CHEMOTHERAPY, ARTIFICIAL HYDRATION AND NUTRITION)
-GENERAL NURSING CARE FOR COMFORT AND PALLIATION
3. QUALITY OF LIFE
-CRITERIA OF QUALITY OF LIFE: CAPACITY TO THINK, i
FEEL, INTERACT !
WITH OTHERS
-IMPEDIMENTS TO QUALITY: SEVERE PAIN AND SUFFERING (OR
EFFECTS OF
MEDICATION TO RELIEVE THEM), AND ANY OTHER CONDITION
THAT THWARTS CAPACITY TO THINK, FEEL, AND INTERACT '
WITH OTHERS
Source: Callahan, D. Setting Limits: Medical Goals in
An Aging Society. Simon and Schuster, 1987.
109

Asset Metadata

Creator Rosenquist, Lori L. (author)

Core Title A descriptive analysis of health care rationing: A focus on renal disease and the elderly

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Degree Master of Science

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