The most appropriate next step in the management of this patient's end-stage kidney disease (ESKD) is to recommend non-dialytic therapy. Dialysis may be beneficial in prolonging life with a good quality in many older patients; therefore, age itself is not always an absolute limiting factor in deciding whether dialysis is appropriate for a specific older patient. However, studies have shown that very elderly patients with a high burden of comorbid conditions and poor functional status may live as long or longer with non-dialytic therapy that is focused on alleviating symptoms and maximizing quality of life. Moreover, most nursing facility residents have a progressive decline in functional status after starting dialysis. Therefore, in this very elderly resident with multiple comorbidities who lives in a nursing facility, pursuing non-dialytic therapy is the most appropriate recommendation. The option of non-dialytic care should not be seen as refusal to provide care or provision of a lower level of care than those receiving dialysis, but rather as an appropriate recommendation based on expected outcomes in these patients. Palliative medicine and hospice services can be helpful in managing patients who choose this mode of therapy.

In older patients who choose to pursue dialysis, there are few definitive data regarding outcomes with hemodialysis versus peritoneal methods, although hemodialysis is typically chosen more frequently by older adults. However, neither modality is appropriate in the patient given his advanced age and other clinical circumstances.