NBC Commentator Dr. Arthur Caplan Calls Dialysis Cruel and Lousy Care

By Peter Laird, MD

NBC news followed it's recent series on dialysis with a commentary online by Arthur Caplan, Ph.D., director of the Center for Bioethics at the University of Pennsylvania where he characterized dialysis as lousy, unnecessary and cruel:

Dialysis payment program is costly in too many ways

Last, it is hard to die in an American hospital without being put on dialysis. Because kidney failure is such a frequent complication of terminal illness, the population of people needing dialysis is far larger than Shep Glazer or the lawmakers who authorized the benefit ever imagined. Because there is guaranteed money to be made putting the ill on dialysis, that's often exactly what happens.

The End-Stage Renal Dialysis program was an act of noble compassion. But ripping off the American people by allowing too many people to receive lousy or unnecessary care is not compassionate at all. It is cruel.

Once again, in the short space of a few days, NBC news has gone down the path of what I consider to be biased reports that casts a shadow over all dialysis patients who benefit from the 1972 ESRD Medicare program. While there are many patients who develop renal failure as a part of a terminal illness, Dr. Caplan should be well aware that the mortality for such patients is greater than 50-60% during that hospitalization alone which persists for those that survive and are discharged especially to nursing homes after such an acute illness.  

Proper informed consent with patients and family members keeps many patients who truly will not benefit from acute renal dialysis in this situation from becoming chronic patients. Many patients in this situation that survive the hospitalization choose hospice over dialysis. Once again, when it came time to comment on dialysis issues, NBC chose a transplant expert showing a continued and openly biased approach to a dialysis story.

DESCRIPTION OF BIOETHICS EXPERTISE

Arthur Caplan, Ph.D - RESEARCH INTEREST:
Transplantation research ethics, genetics, reproductive technologies, health policy, and general bioethics

ABOUT:
Currently, the Emmanuel and Robert Hart Director of the Center for Bioethics and the Sydney D Caplan Professor of Bioethics at the University of Pennsylvania in Philadelphia.

If we return to the true history of the Medicare ESRD program, the fact that government officials and industry leaders are responsible for the uniquely America poor outcomes. Data supplied by Richard Rettig,(page 3) a Rand Corporation scholar, shows that in 1972, in-center dialysis costs were between $27,600 - $30,500 while at the same time home dialysis costs were only $14,900 for the first year of therapy and only $7000 for each year there after.  Dr. Caplan failed to use the correct figures in his report which shows continued bias in my opinion since at that time 80% of patients by some accounts dialyzed at home. Similar cost differentials  by magnitude of differences still prevail today between in-center dialysis and home based dialysis modalities, yet the outcomes are as much as 60% better with the home programs.

Nevertheless, in 1978 congressional hearings, led by what in my opinion was false or at the very least incorrect testimony by Dr. Edmund G. Lowrie, a high ranking official at that time in the National Medical Care Inc., the large for profit dialysis corporation, congress paradoxically adopted in-center, ultra-short dialysis as the standard treatment of choice. Shortly thereafter, the NCDS led once again by Dr. Lowrie cemented the standard of care for dialysis in America in-center as ultra-short, fast paced, "efficient" hemodialysis that is now responsible for the 2.5 times higher mortality than with a similar elderly population with many diabetic patients in Japan.

If NBC news wishes to continue what are in my opinion biased reports, I am not in a position to do any more than report these facts.  My largest concern is that any future actions by congress and CMS would take a clearer picture of the dialysis industry than NBC has certainly demonstrated in the last few days on any future considerations for the Medicare ESRD program. If cuts are to be made in the program, let it be due to improvements of care and economies of scale taking advantage of the home dialysis option before any politician or physician fails to prescribe care to elderly and infirm patients who may benefit as much as younger and more fit patients when dialysis is done in a compassionate and caring manner, longer, slower and gentler.

For those with a poor prognosis, hospice remains the better option, but fortunately, this is a small segement of the Medicare ESRD program. Dr. Caplan's commentary in my opinion lends a false impression that they are single handedly responsible for the cost and outcomes of the program. The real reason the program is so expensive is because we have only 1-2% of patients on home dialysis when as many as 30% or more could utilize this safe and more effective option.

In addition, those in-center recieve shortened sessions filled with rapid fluid removal which leads to cramping, nausea, vomiting and at times completely passing out. Instead of slowing down the machine and adding as little as 30 minutes more to a session, the American nephrologist often resorts to adding salt to the cleansing fluid which causes patients to gain too much fluid between sessions and damages the heart. Many have concluded that it is the way America practices dialysis that led to our poor outcomes, not because of our patient population.

I invite NBC news to interview patients such as Bill Peckham and and Dan Larabee and review their videos on the Rogue River last summer setting up portable dialysis units all the way down this wilderness river that is a challenge to young and healthy people let alone, a "dialysis" patient.  

 

It is time to tell the truth about dialysis as the noble experiment it truly is as the first real gift of life to thousands of uremic patients instead of what is, in my opinion, continued media and political lies about how dialysis truly impacts the lives of dialysis patients. Perhaps instead of perpetuating the myths of dialysis, NBC and Dr. Arthur Caplan would add more to the commentary by exploring the corruption of congressional actions by dialysis industry insiders that reaped the huge profits that make the American dialysis experience the most expensive in the world with the worlds worst outcomes.

Comments

[Trish Rundle]

After 25+ years as a Nephrology nurse i have seen the growth of dialysis as a business. One of the top two companies has systematically gotten rid of most of the older experinced nurses replacing them with younger new grads. Clinics are run by business majors with only as many RNs as are required by law. Nurses are gone from the management arena in this company.

[Peter Laird, MD]

My son interviewed a month ago for a position with a large dialysis organization and was told in the interview that after a year or so in the company, he would supervise two or three dialysis units. Fortunately, he is pursuing other options, I really didn't want him to be a part of this company at all.

This with a business degree and absolutely no medical background in any health related field. Trish, you are so right that it is the business majors running our dialysis units today and not the nurses. Even worse, the doctors have further abdicated their roles as leaders as well and letting the business majors to direct their practices.

[MooseMom]

Misplaced guilt wastes more energy than worrying.

[Martha Barnes]

I am a Nurse Manager with a large, non-profit corporation. Our dialysis centers are run by nurses, not business managers, and I can tell you that we all know each one of our patients. Patients have a choice about which dialysis center to use. We have never refused a patient who has no funding. The patients are the reason for our existence. Perhaps NBC and Dr. Caplan should actually spend time with a dialysis patient whose life depends on our care.

[MooseMom]

I want to go to Martha's clinic!!

[Peter Laird, MD]

Thank you Martha for taking care of my fellow renal patients in the traditions of medicine that made this such a wonderful profession. If NBC or Dr. Caplan ever calls you, please let me know so I can post it.

God bless,

Peter

[Lyn Tubbs RN, CNN]

Martha, You are lucky to work for a non-profit clinic. Of my almost 30 years in dialysis I worked 5 years for a "for-profit" company in a chronic setting. What Dr. Caplan said is true. As for Hospice patients, I hate to tell you but they still get dialysis. It is time to put nurses back in the dialysis units and give patients decent care. I truly hope that CMS can do some house cleaning.

[ExExZonie]

"those in-center recieve shortened sessions filled with rapid fluid removal which leads to cramping, nausea, vomiting and at times completely passing out."

I thought it was just me! I feel like I'm interrupting the staff to tell them I feel lightheaded or sick to my stomach toward the end of my sessions. Several times my blood pressure has gone down to 50 or 60 over 40 or some such. And this is after taking off only a kilogram (over 1.5 hours). Just yesterday it was 63 over something with just five minutes left to go, taking off 1 kilogram over three hours.

I'm supposed to start home hemo soon but it keeps getting put off because there is only one training nurse for all the clinics in this practice. All this makes trying to get to work on time after dialysis without feeling like crap, difficult.

I imagine if nephrologists spent a couple of weeks sitting on in-center hemodialysis machines to simulate being a uremia patient, they'd lobby for researchers to find something better.

[Leo]

I am a swedish medical engineering student last week we had a lecturer who told us about dialysis in the states and that the treatment time was being shortend on economic grounds, every one was surprised that this could be allowed to happend. we talked about lightheadednes and vomiting as a result of fast treatment. swedish patients on dialysis do not suffer from vomiting or dissyness becouse they spend more time on the machines, he told us about an extrem case in france where patients were on dialysis for up to eight hours and these patients lived longer then others who spent less time on dialysis. currently a classmate and i are doing our thesis work in wich we are making a dialysis machine, our hope is to devolep a filter that will clean the blood from the same amount of waste producets in one circulation as the curent one those in three circulations, there by shortning the time spent on dialysis by two thirds without the negtive effects such as vomiting and dissyness.
which us good luck

[MooseMom]

Oh, good luck to you, Leo!! Less time on the machine but with better results...that sounds like a miracle!