Dialysis is a medical treatment that performs the functions of failing kidneys, removing waste products and excess fluid from the blood. It becomes medically necessary for individuals experiencing end-stage kidney failure, a condition where kidneys can no longer adequately clean the blood. The decision to refuse or withdraw from this life-sustaining treatment carries serious implications, and understanding these consequences is important for individuals and their families.
Understanding Kidney Failure and Dialysis
Healthy kidneys filter waste products and excess fluid from the blood, which are then excreted as urine. When kidneys fail, a condition known as end-stage renal disease (ESRD), these substances build up to dangerous levels. ESRD is the final stage of chronic kidney disease, where kidney function has significantly declined. Without treatment, this accumulation can severely impact health and lead to life-threatening complications.
Dialysis functionally replaces the kidneys’ filtering action. Hemodialysis, a common type, involves diverting blood from the body through an artificial kidney machine called a dialyzer. Inside the dialyzer, a semipermeable membrane separates the blood from a cleansing fluid called dialysate, allowing waste and excess water to pass into the dialysate before the cleaned blood is returned to the body. This process typically takes three to four hours and is performed multiple times a week.
Peritoneal dialysis uses the lining of the abdomen, the peritoneum, as a natural filter. A soft tube, or catheter, is surgically placed into the abdomen, through which a sterile cleansing fluid, dialysate, is introduced into the peritoneal cavity. Waste products and excess fluid from the blood vessels in the peritoneum diffuse into this fluid, which is then drained and discarded after a few hours. This method can be performed at home, sometimes while a person sleeps, offering more flexibility.
The Body’s Decline Without Dialysis
Refusing or discontinuing dialysis for end-stage renal disease leads to a progressive decline as toxins and fluids accumulate. Without the filtering process, waste products like urea and creatinine build up in the bloodstream, a condition known as uremia. This accumulation affects nearly all organ systems, leading to severe symptoms.
Initial symptoms often include fatigue and weakness. Nausea, vomiting, and a metallic taste in the mouth are common as waste products irritate the digestive system, leading to poor appetite and potential weight loss. Fluid retention becomes pronounced, causing swelling (edema) in the hands, ankles, feet, and face, and can lead to shortness of breath if fluid accumulates in the lungs.
As the concentration of toxins rises, neurological symptoms can develop, including confusion, difficulty concentrating, and brain fog. This can progress to muscle cramps, restless legs, headaches, and seizures. The imbalance of electrolytes and hormones contributes to systemic dysfunction, impacting heart rhythm and potentially causing chest pain.
The skin may become dry and itchy due to the buildup of mineral deposits. Ultimately, the accumulation of waste products and fluid leads to organ failure. This progression eventually results in a coma and, typically, death within days to a few weeks, though individual timelines can vary based on residual kidney function and overall health.
Reasons for Refusing Dialysis
The decision to refuse or withdraw from dialysis is deeply personal and often arises from various factors. For many individuals, the burden of the treatment itself is a significant consideration. Dialysis requires a substantial time commitment, with multiple sessions per week for hemodialysis or daily exchanges for peritoneal dialysis, which can disrupt daily life and independence.
Physical discomfort is another common reason, as patients may experience side effects such as fatigue, muscle cramps, and pain during or after treatments. The desire for an improved quality of life, even if it means a shorter life, often outweighs the benefits of continued treatment. Some individuals may feel that dialysis no longer improves their well-being, especially if their health is declining despite the therapy.
Co-existing medical conditions, or comorbidities, can make dialysis challenging and contribute to a poor prognosis. Advanced age and the presence of multiple other health problems can diminish the effectiveness of dialysis and increase its physical toll. Personal beliefs and values also play a role, with some individuals prioritizing comfort and dignity in their final stages of life over extending life through burdensome medical interventions.
Support and Ethical Considerations
When an individual chooses to refuse dialysis, support systems are important for both the patient and their family. Palliative care focuses on managing symptoms, relieving pain, and enhancing the quality of life for those with serious illnesses, and it can be provided alongside ongoing medical treatment. This approach helps address physical symptoms like pain, nausea, and shortness of breath, as well as emotional and spiritual needs.
Hospice care is an option when curative treatments are no longer pursued and a prognosis of six months or less is anticipated. Hospice teams offer specialized support to ensure comfort and dignity during the final stages of life, often allowing patients to remain at home. They provide symptom management, assistance with daily tasks, and emotional support for the patient and their loved ones, helping to alleviate the burden on caregivers.
Ethical considerations are central to the discussion of refusing medical treatment. The principle of patient autonomy affirms an individual’s right to make informed decisions about their healthcare, including the right to refuse life-sustaining treatments. This right is based on the idea that competent adults can choose treatments aligned with their values and goals. Healthcare providers are responsible for ensuring informed consent, meaning patients fully understand their condition, treatment options, potential outcomes, and the consequences of refusal before making a decision.