Abstract

Background: Hepatorenal syndrome (HRS) has traditionally been associated with high in-hospital mortality in the absence of liver transplantation. However, the underlying data are uncertain. The question of whether to recommend initiation of hemodialysis for patients with HRS who are not considered candidates for liver transplant is therefore both clinically and emotionally difficult. Methods: We conducted a vignette-based survey of physicians from internal medicine subspecialties (nephrology, critical care, and palliative care) involved in dialysis decision-making for critically ill patients with HRS. Our clinical vignette described a critically ill patient with HRS requiring multiple vasopressors, who was not felt to be a candidate for liver transplantation. The survey assessed physician recommendations regarding dialysis initiation, expected survival, and perceived likelihood of life extension, recovery, and harm with dialysis, as well as decision-related emotional distress. Associations with reported distress were evaluated using multivariable linear regression. Results: 53 physicians (19 nephrology, 21 critical care, 3 palliative care, 4 trainees) responded. The majority of physicians (71%) did not recommend hemodialysis, even though the average rating for dialysis extending life was 54.6 out of 100. Physicians reported high distress related to this decision as measured using a validated scale. Higher provider religiosity was associated with lower reported distress (β = –0.82; 95% CI –1.55, –0.10; p = 0.03). Conclusion: Decision-making about dialysis initiation in the critically ill patient with hepatorenal syndrome is associated with distress in all physician disciplines among our study participants, with only religiosity identified as a protective factor. Further research is required to understand how to best assist physicians and explore the reasons for this finding.

Keywords

hepatorenal syndrome, hemodialysis, dialysis initiation, liver transplantation, critical illness, physician decision-making, emotional distress, religiosity, palliative care