An 84-year-old with stage 5 CKD and severe frailty is approaching the need for renal replacement therapy. His son insists he should start dialysis. How would you approach this?

Question

An 84-year-old man has an eGFR of 8, Clinical Frailty Scale 7, ischaemic heart disease, and lives in a residential home. He is fatigued but not uraemic. His son, who lives abroad, has told the team by phone that 'everything must be done'.

Accepted Answer

My starting point is that this is his decision if he has capacity, and most patients in this situation do. So I would assess capacity for this specific decision and then have the conversation with him, with his son involved by phone with his consent. I would say to the son directly and kindly that his view matters and will inform us, but that it is not his decision to make, and that what would help most is telling us what his father has always valued. I would then present both pathways honestly and concretely. Dialysis would mean three half-days a week, transport to and from the unit, vascular access with its own complications, and a significant chance of hospitalisation. Conservative kidney management is not withdrawal of care — it is an active pathway with anaemia management, symptom control, dietary and fluid advice, specialist nurse follow-up and planned palliative input, delivered where he lives. I would be honest about outcomes and frame them around frailty rather than age: in patients with a Clinical Frailty Scale of 7, dialysis often does not extend life meaningfully, and much of any survival gained is spent travelling to and receiving treatment rather than at home. I would ask him what matters to him — time at home, independence, being able to see his family, avoiding hospital — and let that drive the recommendation rather than the eGFR. I would involve the renal MDT, the low clearance nurses, palliative care and the residential home, arrange a ReSPECT conversation, and document the discussion in detail. I would also make clear the decision is reviewable: if he changes his mind, or becomes symptomatically uraemic, we would revisit it.

Conservative Kidney Management Versus Dialysis

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