The ethics of AKI in the ICU: when can (should) you say "no"?

Many older adults with kidney failure and comorbidities may not live any longer with dialysis than without it. However, the de facto default practice is to start dialysis in most patients with progressive stage 5 chronic kidney disease. Medical anthropologists have described two factors contributing to the dialysis default: changing societal expectations resulting in a "biomedicalization of aging" and a "technological imperative" reflected in the difficulty of saying "no" to life-extending interventions, regardless of age, frailty, and complicating, debilitating medical conditions. Commentators have noted that default options are powerful and may be harmful to some patients. They have emphasized that to counter the clinical momentum of default options; it is necessary for clinicians to engage such patients and their families intentionally and explicitly in the process of shared decision-making. This lecture will present the evidence for the dialysis default and a patient-centered approach to respond to it.