Practical Considerations in Dialysis Withdrawal: Title and subTitle Break"To Have That Option Is a Blessing"

In April 2003, Cohen et al¹ introduced Mr D, an elderly man with dementia whose family struggled to make the decision to terminate maintenance hemodialysis after 10 years. The authors suggest that cessation of life-support treatment for patients with end-stage renal disease should generally be considered when the burdens of therapy substantially outweigh its benefits. Decisions to withdraw dialysis now precede 1 in 4 deaths of patients who have end-stage renal disease. The authors recommend use of guidelines that have been recently published to assist clinicians in making these complex and emotionally charged determinations. The guideline principles include: relying on shared decision making by all participants, obtaining informed consent, estimating the prognosis on dialysis, adopting a systematic approach for conflict resolution of disagreements, honoring advance directives, and ensuring the provision of palliative care. Cohen et al discuss the stages and methods for implementing these guidelines to help physicians facilitate a comfortable and well-monitored death. Mr D's physicians took a great deal of time to help the family with their deliberations. After much discussion over several months with Mr D's primary care physician and nephrologist, the decision to cease dialysis was made. Mr D died peacefully in the terminal care unit of a hospital 5 days later, with his family nearby.

Mr D's son was interviewed again by a Perspectives editor on June 9, 2003.

The only significant recommendation that I would have, if I had to go back and do it over again, would be that my activities and the level of intensity that I would have devoted to the whole issue would have gotten into high gear several years earlier. I would say overall that one of the difficulties that I had is that the doctors that I talked to perhaps should have more forcefully stressed the severity of the situation and the imminence of general decline. This goes way back, several doctors, to when he was still living at home, on his own, a few years before and hadn't developed the most acute symptoms of kidney failure. I didn't really understand the complications from the things that he wasn't taking care of himself.

In retrospect, I would say that my one regret is that we should have stopped treatment perhaps a few months earlier. Two years prior to his death, we found him a very, very good doctor, that I was extremely happy with. Someone who really took the time and studied all of his history and case, and my question to him was, "Is there hope that we can improve my father's condition?" And he felt there was. When he first started manipulating my father's medications, indeed, he started to get better. What I wasn't aware of was that he was getting better in the process of a general, inexorable decline. I think that my hope for having him get better was unrealistic and needed to be somewhat modified. Communication about the hopelessness of the situation would have been useful. I might have stopped treatment maybe 3 or 4 months earlier. The thing that happened in this particular case is that the doctor who I found for my dad really earned my trust by doing an excellent job. I could tell he was doing an excellent job because the people before had been sloppy and careless. One of the things that you have to get used to when you're a doctor is that all of your patients are going to die, especially if you're a gerontologist. So, that kind of businesslike attitude that doctors have to have to protect themselves comes off as insensitivity to the family of the patient. If it's not counterbalanced by a demonstration of really taking the time and paying attention, to build a certain level of trust, when it's time to deliver the news that it's time to stop treatment, people are not necessarily going to trust you.

I'm giving advice that I realize is going to be hard to practice, but that's the way I see it.