For elderly patients over 75 with end-stage renal disease and high comorbidity burden, dialysis and conservative management (symptom-focused non-dialytic care) are genuinely contested alternatives. Murtagh et al.’s 2011 CJASN study comparing 202 high-comorbidity patients aged 75 and over found that dialysis provided a median survival advantage of only 6–12 months over conservative management, with no statistically significant quality-of-life benefit at most time points. Conservative management patients spent significantly less time in hospital and reported better symptom control for certain measures in their final months. Davison’s 2010 study found approximately 30% of high-comorbidity elderly patients who started dialysis expressed significant regret within 12 months, primarily because the treatment burden — three four-hour sessions per week, strict dietary and fluid restrictions, fatigue — exceeded their perceived benefit in the context of their functional status and life goals.
The conservative management pathway, when supported by adequate palliative and symptom care, shows consistently high decision satisfaction in well-counselled cohorts. Among Murtagh et al.’s conservative-management patients, surrogate and family regret was approximately 10% — concentrated in cases where patients or families felt information had been inadequate or where the decision was made under time pressure. ERA Registry data across European centres show that conservative management uptake in the 75+ ESRD population has grown steadily from 2010 to 2023, reflecting widespread clinical recognition of the modest survival benefit in this group; in centres with dedicated conservative management programmes, the rate of patients reversing their decision to start dialysis is below 10%.
The action-dominates pattern in this entry reflects a specific, bounded population: elderly, frail, high-comorbidity ESRD patients. For younger patients or those with lower comorbidity burden, dialysis provides substantially greater survival benefit and the regret distribution would look very different. The dominant predictor of regret on both sides is decision quality — whether patients received adequate information about prognosis, treatment burden, and alternatives without time pressure, and whether their own values and priorities were elicited. The difference between well-counselled and poorly-counselled decisions is larger than the intrinsic difference between dialysis and conservative management. The clinical implication is that the decision conversation — not just the decision — is the intervention most likely to reduce regret.