TREATMENT OPTIONS FOR END-STAGE RENAL-DIS EASE IN A COMMUNITY-HOSPITAL - ETHICAL ISSUES AND CLINICAL DECISIONS

We studied the characteristics of patients reaching end-stage renal di sease and the decisions regarding dialysis in a community hospital dur ing 1992-93. The following data were recorded: decision date; patient' s age, sex, renal diagnosis, Karnofsky activity functional class, reas on for exclusion from dialysis where applicable, survival and choice o f dialysis option. Seventy four patients were enroled (102 per million population per year); 18 were not dialysed (24 %) and 56 were started on regular dialysis (76 %). The patients not dialysed comprised 6 men and 12 women, had a mean age of 74.8 +/- 10.9 (SD) years and a Karnof sky index of 48 +/- 11 %. The reasons for not starting dialysis were d ementia (8 patients), personal decision (7) advanced malignancy (4) an d suicide (1). There nas family consent to the decision in all except the last case. The dialysed patients comprised 33 men and 23 women, ha d a mean age oi 59.5 +/- 18.0 years and a Karnofsky index oi 8 7 +/- 1 5 %. The choice of dialysis options was assisted hemodialysis in 64 % and home peritoneal dialysis in 36 %. No patient chose home hemodialys is. Our experience is in line with the expected incidence of non-dialy sed uremic patients. These patients pose intriguing problems in ethics , economics and support care. Involving the patients in decisions abou t dialysis treatment reinforces their integration into the programme a nd dictates the diversity of dialysis options with economic and organi sational consequences.