Is Evidence-Based-Medicine Always the Gold Standard in Geriatric Nephrology?

Elderly patients worldwide visit doctors for consultation on their health problems. It is necessary for all health care providers to do their best to provide optimal care based on evidence-based-medicine (EBM) [1,2]. The concept of geriatric medicine has been developed for the purpose of promoting discussions on better care for elderly patients with disease [3]. Physical frailties or a variety of symptom burdens including cognitive impairment and organ insufficiency such as chronic heart failure or chronic kidney disease (CKD) are detected frequently in elderly patients [4]. Doctors are therefore required to be aware of these difficult conditions in order to establish a better plan of care.

In this regard, the American Society of Nephrology has emphasized the importance of careful care especially for elderly patients with CKD [5], and defined the concept for these academic frameworks as “Geriatric Nephrology (GN)” [6]. These publications are recommended reading for nephrologists in order to increase their knowledge and improve clinical practice. In my opinion, decisions regarding dialysis or end-of-life in elderly CKD patients are especially important issues in the field of GN. Similar to other fields of medicine, nephrology in CKD has developed to improve outcomes of patients based on EBM or clinical guidelines. It is therefore important for nephrologists to use EBM to adequately manage physical parameters of their patients such as hypertension, glycemic control, renal anemia, and mineral bone disease.

Nevertheless, it is sometimes difficult to adapt EBM concepts to solve other problems (i.e., decisions on care). Nephrologists are occasionally reluctant to provide dialysis care for elderly CKD patients with limited life expectancy due to serious cormobidities, such as the terminal phase of malignancy or functional impairment, frailty, or dementia, irreversible disturbance of consciousness due to cerebrovascular disease, uncontrollable respiratory distress secondary to chronic heart failure or lung disease. While the well-established consensus in EBM is that dialysis should be initiated for CKD patients with serious disease, the other optional treatments that should be considered in these patients are nondialytic therapy [7,8] or renal palliative care [9]. A number of nephrologists recognize that dialysis therapy does not always improve the outcome of these patients and may also be concerned that the patients may suffer from physical or psychological burden related to dialysis therapy itself [10]. Furthermore, EBM may not be helpful in the process of providing better management for patients. In that situation, is it necessary to develop a kind of EBM for these sensitive problems in GN? I am convinced that it may be difficult, or even impossible to achieve these objectives in the future. We generally carry out a clinical investigation such as a randomized-control-trial (RCT) in a specific field of medicine, to obtain evidence on interventions and establish EMB guidelines. The evidence is usually based on statistical analysis of data from selected patients. Although a valuable study such as the renal epidemiology and information network (REIN) [11] based on EBM can be helpful for dialysis decision making of a large number of CKD patients, however, we, nephrologists need to carefully adapt these evidence carefully to elderly CKD patients with sever multicormobidites such as mentioned above.

Moreover, a kind of EBM related to dialytic care may not always be useful for us to consider the ethical issues worth discussing in GN, such as decision making for end-of-life care for severely ill elderly patients with CKD. “Narrative Based Medicine” (NMB) is regarded as a meaningful idea as it can be understood in the context of patient-centered medicine [12]. Physicians are recommended to share stories or background when treating patients using NBM. It is also essential that physicians establish and maintain a preferable patient-physician communication [13].

While it may take some time and patience for physicians as well as patients or their relatives to achieve better care based on NBM, it may be helpful to consider ethical problems related to GN. I personally agree with the clinical practice of NBM and consider it is also probably useful for reducing the mental distress of both healthcare providers and patients in difficult situations such as decision making for end-of-life care.

I would like to emphasize that not only medical concepts but also our past clinical experience can be important in NBM.

In our case, first we take sufficient time for listening patients’ story about their life, disease, family background and their preference for treatment plan. Following these dialogue, we usually explain that a dialytic therapy may be one of the recommendable care regarding a concept of EBM. Simultaneously, we also show an optional treatment plan such as non dialytic therapy or a kind of palliative care for patients who are reluctant to be under dialysis or aren’t able to recognize the therapy due to sever dementia. It may be necessary that we indicate our patients who are considering choose a nondialytic therapy the detail about life threatening symptoms such as respiratory distress or disturbance of consciousness due to uremia.

Besides, we assure that every health care provider is willing to prepare a nonabandoment treatment and follow up for patients even if they decline to receive a dialytic therapy [14].

As described above, through these step by step careful communications, we try to ascertain the patient’s perspective and respect their choice for treatment preference. We recognize the process as a NBM in GN.

Although some recommended clinical guidelines are available accumulation of novel case reports related to the ethical issues of GN may also be valuable [15,16]. As mentioned above, I conclude that EBM cannot always be the gold standard in GN.

I am afraid that a large number of young medical fellows or nephrologists are not very interested in the field of GN. As a senior or leading doctor in our hospital, I am currently trying to promote an education program on GN for junior doctors. I hope that young nephrologists will become more interested in care that includes NBM in the context of GN. In summary, it may be worthwhile considering the integration of both EMB and NBM in order to develop better care of our elderly patients.

This report was supported by the non-profit organization, the Epidemiological and Clinical Research Information Network (ECRIN).