Withdrawal from and withholding of dialysis
- Holly M Koncicki, MD
Holly M Koncicki, MD
- Assistant Professor
- Icahn School of Medicine at Mount Sinai
- 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.
- Levinsky NG. The organization of medical care. Lessons from the Medicare end stage renal disease program. N Engl J Med 1993; 329:1395.
- Klahr S. Rationing of health care and the end-stage renal disease program. Am J Kidney Dis 1990; 16:392.
- United States Renal Data System. USRDS 2009 Annual Data Report. U.S. Department of Health and Human Services. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD. Am J Kidney Dis 2010; 55(Suppl 1):S1.
- Singer PA. Nephrologists' experience with and attitudes towards decisions to forego dialysis. The End-Stage Renal Disease Network of New England. J Am Soc Nephrol 1992; 2:1235.
- Hirsch DJ, West ML, Cohen AD, Jindal KK. Experience with not offering dialysis to patients with a poor prognosis. Am J Kidney Dis 1994; 23:463.
- Morton RL, Turner RM, Howard K, et al. Patients who plan for conservative care rather than dialysis: a national observational study in Australia. Am J Kidney Dis 2012; 59:419.
- Sekkarie MA, Moss AH. Withholding and withdrawing dialysis: the role of physician specialty and education and patient functional status. Am J Kidney Dis 1998; 31:464.
- Moosa MR, Kidd M. The dangers of rationing dialysis treatment: the dilemma facing a developing country. Kidney Int 2006; 70:1107.
- United States Renal Data System. 2015 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 2015.
- Bleyer AJ, Tell GS, Evans GW, et al. Survival of patients undergoing renal replacement therapy in one center with special emphasis on racial differences. Am J Kidney Dis 1996; 28:72.
- Mailloux LU, Bellucci AG, Napolitano B, et al. Death by withdrawal from dialysis: a 20-year clinical experience. J Am Soc Nephrol 1993; 3:1631.
- Cohen LM, Germain MJ, Poppel DM. Practical considerations in dialysis withdrawal: "to have that option is a blessing". JAMA 2003; 289:2113.
- ESRD network of New England. 2001 Annual Report to the Centers for Medicare and Medicaid Services. New Haven, Conn: Tyco Printers; July 2002; 60.
- Murtagh F, Cohen LM, Germain MJ. Dialysis discontinuation: quo vadis? Adv Chronic Kidney Dis 2007; 14:379.
- Bajwa K, Szabo E, Kjellstrand CM. A prospective study of risk factors and decision making in discontinuation of dialysis. Arch Intern Med 1996; 156:2571.
- Gessert CE, Haller IV, Johnson BP. Regional variation in care at the end of life: discontinuation of dialysis. BMC Geriatr 2013; 13:39.
- Canadian Organ Replacement Register. 1993 Annual Report, Canadian Institute for Health Information, Don Mills, Ontario, Canada, March 1995.
- Aggarwal Y, Baharani J. End-of-life decision making: withdrawing from dialysis: a 12-year retrospective single centre experience from the UK. BMJ Support Palliat Care 2014; 4:368.
- van Biesen W, van de Luijtgaarden MW, Brown EA, et al. Nephrologists' perceptions regarding dialysis withdrawal and palliative care in Europe: lessons from a European Renal Best Practice survey. Nephrol Dial Transplant 2015; 30:1951.
- Murphy E, Germain MJ, Cairns H, et al. International variation in classification of dialysis withdrawal: a systematic review. Nephrol Dial Transplant 2014; 29:625.
- Moss AH. Dialysis decisions and the elderly. Clin Geriatr Med 1994; 10:463.
- Leggat JE Jr, Bloembergen WE, Levine G, et al. An analysis of risk factors for withdrawal from dialysis before death. J Am Soc Nephrol 1997; 8:1755.
- Neu S, Kjellstrand CM. Stopping long-term dialysis. An empirical study of withdrawal of life-supporting treatment. N Engl J Med 1986; 314:14.
- Cohen LM, McCue JD, Germain M, Kjellstrand CM. Dialysis discontinuation. A 'good' death? Arch Intern Med 1995; 155:42.
- Tobe SW, Senn JS. Foregoing renal dialysis: a case study and review of ethical issues. The End-Stage Renal Disease Group. Am J Kidney Dis 1996; 28:147.
- Thomas BA, Rodriguez RA, Boyko EJ, et al. Geographic variation in black-white differences in end-of-life care for patients with ESRD. Clin J Am Soc Nephrol 2013; 8:1171.
- McDade-Montez EA, Christensen AJ, Cvengros JA, Lawton WJ. The role of depression symptoms in dialysis withdrawal. Health Psychol 2006; 25:198.
- Hussain JA, Flemming K, Murtagh FE, Johnson MJ. Patient and health care professional decision-making to commence and withdraw from renal dialysis: a systematic review of qualitative research. Clin J Am Soc Nephrol 2015; 10:1201.
- Lowance DC. Factors and guidelines to be considered in offering treatment to patients with end-stage renal disease: a personal opinion. Am J Kidney Dis 1993; 21:679.
- Moss AH. To use dialysis appropriately: the emerging consensus on patient selection guidelines. Adv Ren Replace Ther 1995; 2:175.
- Lambie M, Rayner HC, Bragg-Gresham JL, et al. Starting and withdrawing haemodialysis--associations between nephrologists' opinions, patient characteristics and practice patterns (data from the Dialysis Outcomes and Practice Patterns Study). Nephrol Dial Transplant 2006; 21:2814.
- Moss AH, Stocking CB, Sachs GA, Siegler M. Variation in the attitudes of dialysis unit medical directors toward decisions to withhold and withdraw dialysis. J Am Soc Nephrol 1993; 4:229.
- Eiser AR, Seiden DJ. Discontinuing dialysis in persistent vegetative state: the roles of autonomy, community, and professional moral agency. Am J Kidney Dis 1997; 30:291.
- Devita M, Grenvik A. Foregoing life-sustaining therapy in intensive care. In: Textbook of Critical Care, Ayres S, Grenvik A, Holbrook P, Shoemaker W (Eds), WB Saunders, Philadelphia 1995. p.1802.
- Hemmelgarn BR, Manns BJ, Quan H, Ghali WA. Adapting the Charlson Comorbidity Index for use in patients with ESRD. Am J Kidney Dis 2003; 42:125.
- Moss AH, Ganjoo J, Sharma S, et al. Utility of the "surprise" question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol 2008; 3:1379.
- Lowance DC. Withdrawal from dialysis: an ethical perspective. Kidney Int 1988; 34:124.
- Moss AH. Shared decision-making in dialysis: the new RPA/ASN guideline on appropriate initiation and withdrawal of treatment. Am J Kidney Dis 2001; 37:1081.
- Moss AH. Revised dialysis clinical practice guideline promotes more informed decision-making. Clin J Am Soc Nephrol 2010; 5:2380.
- http://www.renalmd.org/Search.aspx?searchtext=shared decision making&folderid=0&searchfor=all&orderby=rank&orderdirection=descending (Accessed on April 05, 2013).
- Swartz RD, Perry E, Schneider C, et al. The option to withdraw from chronic dialysis treatment. Adv Ren Replace Ther 1994; 1:264.
- Cruzan v Director, Missouri Department of Health, 497, US 261, 1990.
- Pickering JH. Death and the law: What is the right to die? Eleventh Annual Leon and Josephine Winkelman Lecture. University of Michigan School of Social Work. Ann Arbor, MI 1989.
- Kerridge I, Lowe M, Mitchell K. Competent patients, incompetent decisions. Ann Intern Med 1995; 123:878.
- Singer PA, Thiel EC, Naylor CD, et al. Life-sustaining treatment preferences of hemodialysis patients: implications for advance directives. J Am Soc Nephrol 1995; 6:1410.
- Holley JL, Nespor S, Rault R. The effects of providing chronic hemodialysis patients written material on advance directives. Am J Kidney Dis 1993; 22:413.
- Holley JL, Nespor S, Rault R. Chronic in-center hemodialysis patients' attitudes, knowledge, and behavior towards advance directives. J Am Soc Nephrol 1993; 3:1405.
- Holley JL, Foulks CJ, Moss AH. Nephrologists' reported attitudes about factors influencing recommendations to initiate or withdraw dialysis. J Am Soc Nephrol 1991; 1:1284.
- Mendelssohn DC, Singer PA. Advance directives in dialysis. Adv Ren Replace Ther 1994; 1:240.
- Perry E, Buck C, Newsome J, et al. Dialysis staff influence patients in formulating their advance directives. Am J Kidney Dis 1995; 25:262.
- Perry LD, Nicholas D, Molzahn AE, Dossetor JB. Attitudes of dialysis patients and caregivers regarding advance directives. ANNA J 1995; 22:457.
- Hines SC, Glover JJ, Holley JL, et al. Dialysis patients' preferences for family-based advance care planning. Ann Intern Med 1999; 130:825.
- Sehgal A, Galbraith A, Chesney M, et al. How strictly do dialysis patients want their advance directives followed? JAMA 1992; 267:59.
- Swartz RD, Perry E. Advance directives are associated with "good deaths" in chronic dialysis patients. J Am Soc Nephrol 1993; 3:1623.
- Cohen LM, Germain M, Poppel DM, et al. Dialysis discontinuation and palliative care. Am J Kidney Dis 2000; 36:140.
- Brown MA, Collett GK, Josland EA, et al. CKD in elderly patients managed without dialysis: survival, symptoms, and quality of life. Clin J Am Soc Nephrol 2015; 10:260.
- O'Connor NR, Kumar P. Conservative management of end-stage renal disease without dialysis: a systematic review. J Palliat Med 2012; 15:228.
- Smith C, Da Silva-Gane M, Chandna S, et al. Choosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract 2003; 95:c40.
- Wong CF, McCarthy M, Howse ML, Williams PS. Factors affecting survival in advanced chronic kidney disease patients who choose not to receive dialysis. Ren Fail 2007; 29:653.
- Chandna SM, Da Silva-Gane M, Marshall C, et al. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant 2011; 26:1608.
- Murtagh FE, Marsh JE, Donohoe P, et al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 2007; 22:1955.
- Couchoud C, Labeeuw M, Moranne O, et al. A clinical score to predict 6-month prognosis in elderly patients starting dialysis for end-stage renal disease. Nephrol Dial Transplant 2009; 24:1553.
- Couchoud CG, Beuscart JB, Aldigier JC, et al. Development of a risk stratification algorithm to improve patient-centered care and decision making for incident elderly patients with end-stage renal disease. Kidney Int 2015; 88:1178.
- O'Connor NR, Dougherty M, Harris PS, Casarett DJ. Survival after dialysis discontinuation and hospice enrollment for ESRD. Clin J Am Soc Nephrol 2013; 8:2117.
- Fissell RB, Bragg-Gresham JL, Lopes AA, et al. Factors associated with "do not resuscitate" orders and rates of withdrawal from hemodialysis in the international DOPPS. Kidney Int 2005; 68:1282.
- Anderson F, Downing GM, Hill J, et al. Palliative performance scale (PPS): a new tool. J Palliat Care 1996; 12:5.
- Schell JO, Green JA, Tulsky JA, Arnold RM. Communication skills training for dialysis decision-making and end-of-life care in nephrology. Clin J Am Soc Nephrol 2013; 8:675.
- A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA 1995; 274:1591.
- Lo B. Improving care near the end of life. Why is it so hard? JAMA 1995; 274:1634.
- Kjellstrand CM. Giving life, giving death: ethical problems of high-technology medicine. Acta Med Scand Suppl 1988; 725:1.
- Berman E, Merz JF, Rudnick M, et al. Religiosity in a hemodialysis population and its relationship to satisfaction with medical care, satisfaction with life, and adherence. Am J Kidney Dis 2004; 44:488.
- 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