But the law has had unintended consequences, kidney experts say. It was meant to keep young and middle-aged people alive and productive. Instead, many of the patients who take advantage of the law are old and have other medical problems, often suffering through dialysis as a replacement for their failed kidneys but not living long because the other chronic diseases kill them.
Kidney specialists are pushing doctors to be more forthright with elderly people who have other serious medical conditions, to tell the patients that even though they are entitled to dialysis, they may want to decline such treatment and enter a hospice instead. In the end, it is always the patient's choice.
One idea, promoted by leading specialists, is to change the way doctors refer to the decision to forgo dialysis. Instead of saying that a patient is withdrawing from dialysis or agreeing not to start it, these specialists say the patient has chosen "medical management without dialysis."
"That is the preferred term," said Nancy Armistead, executive director of the Mid-Atlantic Renal Coalition, a Medicare contractor that collects data and patient grievances.
The phrase, she says, "acknowledges that death is imminent," but it also sends an important message: "We are not just sending people home to die. We are offering palliative care."
A committee of the Renal Physicians Association recently formulated guidelines to use in deciding when dialysis is appropriate. It provides questions that doctors should ask themselves before suggesting the treatment. One is the "surprise" question: Would I be surprised if this patient is dead within a year?
But, said the committee's chairman, Dr. Alvin H. Moss, a nephrologist and ethicist at West Virginia University, the task ahead is like turning around an ocean liner.
"Clearly, when the program was initiated in the 1970s, the hope and expectation was that this program would return otherwise healthy people back into society so they could work and be productive," said Dr. Manjula Kurella Tamura, a kidney specialist at Stanford. But, she added, "dialysis at the end of life is a different sort of treatment."
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