Dialysis in the frail elderly--a current ethical problem, an impending ethical crisis

J Gen Intern Med. 2013 Nov;28(11):1511-6. doi: 10.1007/s11606-013-2494-1. Epub 2013 May 18.


The current practice of hemodialysis for the frail elderly frequently ignores core bioethical principles. Lack of transparency and shared decision making coupled with financial incentives to treat have resulted in problems of overtreatment near the end of life. Imminent changes in reimbursement for hemodialysis will reverse the financial incentives to favor not treating high-risk patients. In this article, we describe what is empirically known about the approach to hemodialysis today, and how it violates four core ethical principles. We then discuss how the new financial system turns physician and organizational incentives upside down in ways that may exacerbate the ethical dilemmas, but in the opposite direction.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Aged
  • Aged, 80 and over
  • Frail Elderly*
  • Humans
  • Medicare / ethics
  • Patient Participation*
  • Physician-Patient Relations / ethics*
  • Professional Autonomy
  • Renal Dialysis / ethics*
  • Renal Dialysis / statistics & numerical data
  • United States / epidemiology