Withdrawal from Dialysis: Why and When?

“Whenever the illness is too strong for the available remedies, the physician surely mustnot expect that it can be overcome by medicine … To attempt futile treatment is to display ignorance that is allied to madness” (Hippocratic Corpus)

BACKGROUND

Hemodialysis (HD) withdrawal is defined as HD discontinuation after an active decision to permanently stop dialysis by the patient, family, healthcare power of attorney, or healthcare team. However, there are currently no uniformly accepted definitions of withdrawal of dialysis.[1] The practice of withdrawal from dialysis also differs significantly between the countries.[2]

In chronic kidney disease 5Ds, questions arise requesting justification of dialysis treatment in terms of therapeutic benefit versus the burden, increasing disease morbidity, and deteriorating quality of life.[3] In clinical practices, decision to withdraw dialysis therapy arises due to realities such as increasing comorbid conditions, acute medical complications, and increasing logistic burden for family.[4] Patients and families often feel that long-term dialysis treatment is burdensome and express doubts when the quality of life and health of individuals deteriorate.[3] Process for approaching patients about dialysis withdrawal is not standardized, and the conversation can be emotionally difficult for patient, family members, and nephrologists. With shared decision-making which involves basic principles of ethics, e.g. autonomy, beneficence, nonmaleficence, and distributive justice, withdrawal from dialysis is ethically and clinically acceptable.[5]

In a study by Shaikh et al., 2018, 64% of patients stopped HD and 17% of patients died while on dialysis. Common reason for dialysis withdrawal is listed in Table 1.[67] Dialysis withdrawal has been reported as a leading cause of death in patients on dialysis for chronic renal failure. Death in patients with renal diseases on dialysis has been classified as: [1]

1. Death preceded by dialysis withdrawal (cause of death: renal related/uremia)

   1. Patient choice but not recommended by the treating medical team

   2. Without significant medical problems other than renal failure

   3. Active decision to withdraw from dialysis treatment

   4. Comorbidity – there may not be significant co-morbidity.

2. Death preceded by dialysis withdrawal (other causes of death, i.e. malignant disease, Myocardial Infarction)

   1. Usually, a shared decision of the medical team and patient/family with significant medical problems other than renal failure

   2. Comorbidity score – usually very high, or in a frail elderly patient.

3. Death on dialysis – No dialysis withdrawal

   1. No decision to withdraw from dialysis

   2. Time from last dialysis until death usually <3 days.

BARRIERS TO INTRODUCTION OF DIALYSIS WITHDRAWAL PROCESS

For most of patients with end-stage renal disease (ESRD), dialysis is considered standard of care. Family members often feel option of withdrawal as giving up, and it will lead to painful death. Many a time, patients and family members have unrealistic hope of cure from the illness.[7] Physician often finds it difficult to discuss the option of withdrawing from dialysis.[8] In some conditions, ethical dilemmas and legal process make withdrawal decision difficult for the patient [Table 2].

SCREENING TOOL TO IDENTIFY PATIENTS IN WHOM WITHDRAWAL FROM DIALYSIS CAN BE CONSIDERED

The gold standard framework proactive identification guidance can be used as a screening tool and to guide the healthcare practitioners for whom withdrawal can be discussed [Table 3].[9] However, withdrawal should be considered only when clinician and team feel that burden of dialysis (nonmaleficence) clearly outweighs the benefit (beneficence). It involves step-wise approach for identification using surprise question, general indicator, and specific indicator for renal diseases.[10]

RECOMMENDATIONS FOR WITHDRAWAL OF DIALYSIS (KIDNEY DISEASE: IMPROVING GLOBAL OUTCOMES GUIDELINES)

In 2015, Kidney Disease: Improving Global Outcomes (KDIGO) developed a roadmap for improving care for patient of ESRD. KDIGO guidelines[11] highlighted the process of introducing conservative care for patients who opts for withdrawal from dialysis. We proposed step-wise approach for withdrawal from dialysis and implementation of end-of-life care pathway[12] [Table 4].

COMMUNICATION AND IMPLEMENTATION OF WITHDRAWAL OF DIALYSIS

The communication regarding withdrawal of dialysis treatment can be challenging and stressful for all, patients, family members, and physicians. This discussion should be conducted in appropriate setting and involving all decision-makers for patients. Patient's primary care physicians and palliative care team can also be involved in discussions. During the conversations, patient's and family members' understanding of disease should be assessed and the physician should help the patient or family members in shared decision-making process. The details of discussion must be documented clearly on patient's medical records and should be informed to the people involved in his care.

CONCLUSION

As the clinical condition of ESRD patients on dialysis deteriorates, with the worsening of performance scores and comorbidity, patient-specific evaluation of burden versus benefit of continuation of HD should be considered by nephrologists. Shared decision-making process with patients and family members will provide opportunity to discuss patient's wishes, goals of care, and option of withdrawal from dialysis to ensure comfort and a dignified, end-of-life care. Palliative care teams should be involved to provide holistic care for the patient.