Kidney medicine is at the forefront of the debate about rationing because of the high cost of the service and the relatively small number who benefit from it.
£40 billion is spent on the Health Service, and two per cent of that will be spent on kidney patients who make up 0.008% of the population, Sir Netar Mallick told the conference. He talked about how we chose to treat people, focussing on the older age range.
Renal failure got more common with age, but when you got into an older age range, the number on treatment fell. Ninety per cent of haemodialysis patients over 65 had at least two comorbid illnesses, and statistics showed that dialysis did not greatly increase life expectancy.
The decision to start treatment had to be made by the doctor and the patient, with no third party having the right to interfere. But doctors did riot control resources and it was here that the tension arose between the pragmatic approach of value for money and the ethical approach of what was right to do.
The doctor must be convinced that the patient would have a good quality of life and the patient had the absolute right to accept treatment or reject it. The decision not to treat is all right, so long as it is a medical decision and not one of lack of resources, said Sir Netar. Where treatment would be valuable, it should be offered as of right, and the State had the responsibility of not denying that right. Standards, which Professor Stewart Cameron had spoken about, were vital in allowing doctors to point to outcomes.
Patients who took the decision to end dialysis would not be likely to die with acute suffering, said Sir Netar. He was answering a question from a woman patient in the audience who said that she had been discussing with a friend what kind of death they could expect if they came off dialysis.
Given that the patient is not in severe heart failure which would make it difficult to keep the lungs clear, it is likely that patients will not die with acute suffering, said Sir Netar. The time it would take to die would vary, but the problem of keeping the lungs clear could be dealt with, and drugs could be used to make the patient comfortable.
Sir Netar had posed the question. How do you decide when it is time to stop? The doctor/patient relationship was paramount, with the patient having the final say. Patients who lost the ability to decide provided a difficulty, and families needed the help of communities like the National Kidney Federation.
Simon Lloyd from Tyneside asked about the right time to ask patients to state their wishes of what should happen if a life threatening situation arose. Sir Netar thought it was something that the Renal Association should look at, as it was a standard of care.