PROLONGING LIFE OR PROLONGING DEATH - COMMUNICATIONS ROLE IN DIFFICULT DIALYSIS DECISIONS

This article investigates the importance of treatment requests made by patients with kidney failure and other life-threatening conditions on nephrologists' treatment decisions. A total of 535 nephrologists from the U.S., Canada, and Britain returned mailed surveys in which they r ead 5 scenarios and then indicated how the patient described in the sc enario should be treated. Results revealed that when patients communic ated their preferences, nephrologists were significantly more likely t o provide dialysis. Although there were no differences among the 3 cou ntries when treatment preferences were not expressed, Americans were m uch more likely to provide dialysis when requested by the patient Wher eas most nephrologists agreed to change treatment decisions at the req uest of the patient, American doctors were less likely to comply with requests to terminate dialysis and were more likely to agree to provid e dialysis for incompetent patients they initially refused to dialyze if asked to do so by the family. In the 3 scenarios in which the patie nts' treatment preferences were unstated, approximately 45% of the doc tors who recommended dialysis still cited the patient's request for di alysis as the most important factor in their decision. This tendency w as more pronounced for American nephrologists. Results suggest the nee d to further investigate the interactions of doctors and chronically i ll patients and to account for the cultural and institutional contexts in which these interactions occur. Finally, physicians need to teach themselves to recognize better the shadow line between prolonging life and prolonging dying and to understand that death should be a human a ct of dignity and not a prolonged mechanical failure that can be fixed with even more technology.