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Withdrawal From Dialysis

When a patient develops complications from dialysis, dialysis withdrawal is a complicated option with potential risks. Learn how to make the right decision for you.

DIALYSIS WITHDRAWAL

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Although both dialysis and renal transplantation are treatment options for patients with CKD, there are patients for whom complications develop, raising the issue of discontinuation of dialysis. In the United States, dialysis withdrawal is the third most common cause of death (15-25%) for patients with CKD.

Patient factors associated with the decision to withdraw from dialysis include:

Advanced age
Advanced atherosclerotic disease
Poorly controlled diabetes mellitus and advanced complications such as
- Loss of vision
- Advanced cardiovascular disease
- Loss of limbs
Higher physical discomfort index

Interestingly, other factors associated with early withdrawal of dialysis include having a higher educational level—perhaps better preparing a person to weigh the pros and cons of prolonging life that is not of good quality—and gender. More women opt to discontinue dialysis than men.

Usually, there is a precipitating cause for the decision to withdraw from dialysis including:

Failure to thrive
Medical complications
Repeated access failure

consult with a medical professional about dialysis withdrawal

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Based on ethical principles and on the law as outlined in the Patient Self-Determination Act of 1990, all patients who are competent have the personal and legal right to withdraw from dialysis. If a patient expresses wishes to withdraw from dialysis, the following steps must be followed by the medical team:

Assessment of possible reversible factors: The medical team should modify any potentially reversible situations that may have precipitated the patient’s decision.
Assessment of the patient’s decision-making capacity: The patient must fully comprehend that the consequences of withdrawing from dialysis include death, usually within one to two weeks. The patient must be able to provide informed consent. All members of the medical team should be involved in the assessment and discussion of the patient’s (or family’s in the event of incompetence) request for dialysis withdrawal.
Assessment of the patient’s motives: The nephrologist must undertake a full dialogue with the patient, preferably over time, to assess that these are indeed the patient’s wishes.
Identification of the presence of proper advance directives: If the capacity for informed consent cannot be restored, it is important to look for a previously-completed advance directive.
Involvement of the family: The medical team must ensure that the patient has informed his or her family and of the decision to stop treatment and the patient or medical team must clearly explain the consequences.
Medical and family support of the patient’s decision: If after repeated discussions, the patient still desires to withdraw, the medical team should support that decision and encourage the family to do the same. All efforts should be made to keep the patient as comfortable as possible. The medical team should explain the options for providing appropriate end-of-life medical care, such as:
- Referring their loved one to a skilled-care facility with round-the-clock care
- Contracting with a visiting nurse or hospice agency to care for the patient at home. This requires the ordering of medical equipment to maximize comfort of the loved one while ensuring quality of care from and safe working conditions for the agency staff. Equipment might include a hospital bed, bedside commode, and portable oxygen.
- Working with all involved to provide care and respect for the patient’s right to dignity and privacy during the end-of-life process.

The caregivers should keep the family closely informed of their loved one’s condition and provide the family with emotional support as their loved one comes to the end of life’s journey on earth.

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