DIALYSIS DECISION-MAKING IN CANADA, THE UNITED-KINGDOM, AND THE UNITED-STATES

This study was designed to determine the extent to which differences i n criteria for dialysis patient selection and availability of financia l resources cause the wide variation in acceptance rates for dialysis in Canada, the United Kingdom, and the United States, We also sought t o determine whether there is agreement among nephrologists in the thre e countries on which patients should not be offered dialysis, We used a cross sectional survey of all members of the Canadian Society of Nep hrology and the Renal Association of Great Britain, and a randomized s ample of 800 members of the American Society of Nephrology. Five case vignettes were presented asking for yes/no decisions on offering or no t offering dialysis, together with ranking of factors considered impor tant, We also inquired about dialysis resources and physician demograp hics, We compared responses by country, More nephrologists from the Un ited Kingdom returned responses (83%) than Canadian (53%) or American (36%) nephrologists, American nephrologists offered dialysis more than Canadian or British nephrologists (three of five cases; P < 0.04 to P < 0.001) and ranked patient/family wishes (three of five cases; P < 0 .057 to P < 0.0001) and fear of lawsuit (P < 0.04 to P = 0.0012) highe r than British or Canadian nephrologists. Canadian and British nephrol ogists reported their perception of patients' quality of life as a rea son to provide (P = 0.0019) or not provide (P = 0.068 to P = 0.0026) d ialysis more often than their American counterparts, Despite these dif ferences, nephrologists from each country did not differ by more than 30% on any decision and ranked factors almost identically. Ten percent and 12% of Canadian and British nephrologists, respectively, but only 2% of American nephrologists, reported refusing dialysis due to lack of resources (P < 0.0001). We conclude that the wide variation in dial ysis acceptance rates in the three countries is somewhat influenced by differences in patient selection criteria and withholding of dialysis by nephrologists based on financial constraints, but that other facto rs, such as differences in rates of patient nonreferral for dialysis, contribute more significantly to the variation. Generally agreed on pr actice guidelines for dialysis patient selection appear possible. (C) 1998 by the National Kidney Foundation, Inc.