Withdrawal from and withholding of dialysis
- Holly M Koncicki, MD
Holly M Koncicki, MD
- Assistant Professor
- Hofstra Northwell School of Medicine
- Lionel U Mailloux, MD, FACP
Lionel U Mailloux, MD, FACP
- Clinical Professor of Medicine
- Hofstra Northwell School of Medicine
- Section Editors
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
- Robert M Arnold, MD
Robert M Arnold, MD
- Editor-in-Chief — Palliative Care
- Section Editor — General Principles of Palliative Care
- Chief, Section of Palliative Care and Medical Ethics
- University of Pittsburgh School of Medicine
A decision to withdraw or withhold dialysis frequently confronts practicing nephrologists. Such decisions are intertwined with complex ethical, psychosocial, and financial issues that are becoming increasingly important, driven both by increasing awareness among patients and families of end-of-life decisions and, in areas of limited resources, possible rationing of resources [1-3].
The universal availability of renal replacement therapy in the United States forces the nephrologist to consider its application in every patient in whom it might be indicated, without concern for rationing therapy. However, foregoing dialysis is assuming more prominence as patients and clinicians recognize limitations in the survival benefit of dialysis in certain populations and the effects on quality of life.
A clinical approach to foregoing dialysis therapy is discussed here. A review of the general ethical issues involved in the care of patients with end-stage renal disease (ESRD) is presented separately. (See "Ethical issues in the care of the patient with end-stage renal disease".)
Clinical aspects of conservative (ie, nondialytic) management of ESRD patients are discussed elsewhere. (See "Conservative care of end-stage renal disease".)
DEFINITIONS AND EPIDEMIOLOGY
Withholding dialysis is defined as foregoing dialysis in a patient in whom it has yet to be initiated in the setting of either acute or chronic kidney disease (CKD). Withdrawal of dialysis means the discontinuation of maintenance dialysis.
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- DEFINITIONS AND EPIDEMIOLOGY
- Associated factors
- ETHICAL AND LEGAL ISSUES
- CLINICAL APPROACH TO WITHHOLDING OR WITHDRAWING DIALYSIS
- Patients with decision-making capacity
- Patients without decision-making capacity
- - Advance directives (living wills or healthcare proxies) in place
- - Advance directives (living wills or healthcare proxies) not in place
- INVOLVEMENT OF FAMILY AND ONGOING CARE
- Informing the family
- Ongoing care after withdrawal of dialysis
- Withholding dialysis
- Withdrawing dialysis
- FUTURE DIRECTIONS
- SUMMARY AND RECOMMENDATIONS