Considerations in starting a patient with advanced frailty on dialysis: complex biology meets challenging ethics.

Nephrologists have focused on the uremic syndrome as an indication for dialysis. The elderly frail renal patient approaching ESRD represents a complex biologic system that is already failing. This patient phenotype exhibits progressive geriatric disabilities and dependence interspersed with shrinking periods of stability regardless of whether dialysis is started. Consequently, the frail renal patient faces challenging treatment choices underpinned by ethical tensions. Identifying the advanced frail renal patient and optimizing the shared decision-making process will enable him or her to make well informed choices based on an understanding of his or her overall condition and personal values and preferences. This approach will also permit nephrologists to fulfill their ethical obligations to respect patient autonomy, promote patient benefit, and minimize patient harm.