The authors begin by quoting the already-known statistics describing the inferiority of catheters compared to fistulas: a 2-3-fold risk of death, a 5-10-fold increased risk of serious infection, an increased risk of underdialysis, and often increased expense as a result of more hospitalizations and vascular procedures. They further cite the depressing statistic that, despite initiatives such as the “Fistula First” compaign, the number of patients being dialyzed via tunneled catheter was 35% greater in 2005 compared to 1996. A whopping 82% of patients in the U.S. initiate dialysis via tunneled catheter!
What can be done to decrease the percentage of dialysis patients using a tunneled catheter, especially when there are many patients who decline fistula placement even when it is anatomically possible? The authors advocate a rather extreme view, based on an ethics argument: they even go so far as to suggest that a nephrologist could decline to treat a patient who insists on continuing dialysis via a catheter, and instead referring them to another nephrologist.
Quoting from the paper: “To assert that physicians should not have the discretion to refrain from patient-requested treatments in which the harms outweigh the benefits is to deny the medical profession the authority to interpret and apply its own defining values embodied in the Hippocratic oath. Such a position denies the nephrologist the authority to refuse to agree to the insertion of tunneled catheters for long-term use in patients who, despite knowing its antecedent risks, choose to defer the creation of a feasible AV access and confounds the physician’s moral imperative, making him or her instead complicit in the patients self-destructive choice.”
I disagree with the authors’ extreme viewpoint–for instance I don’t agree with primary care doctors who refuse to see patients who will not quit smoking–but I understand their level of concern, and something needs to be done to change whatever aspects of the medical culture which is leading to long-term catheter use. One part of the solution is the use of a dedicated “access coordinator”–our dialysis unit got one a few years ago, and though I wasn’t around in the pre-coordinator days I am told that things go much more smoothly with fistula placement now than there used to be.