Dialysis is a medical treatment that performs the life-sustaining function of the kidneys, filtering waste, toxins, and excess fluid from the blood. For individuals with end-stage kidney disease, dialysis is a commitment to life-prolonging therapy. The decision to stop this treatment is a profoundly personal choice, representing a transition from life-prolonging care to comfort-focused care. Stopping dialysis is a widely accepted practice, grounded in the legal and ethical right of a patient to refuse or withdraw any medical intervention.
Patient Rights and Decision Capacity
The decision to withdraw from dialysis is fundamentally based on the principle of patient autonomy, the right of a competent adult to self-determination in healthcare. A patient must demonstrate medical decision-making capacity to make this informed choice. This capacity involves the ability to understand the condition and treatment, appreciate the consequences of the decision, and communicate their final choice. This capacity is distinct from cognitive impairment, as a person with mild dementia can still be deemed capable of making this specific decision.
If a patient is deemed to lack decision-making capacity, the process shifts to a surrogate decision-maker, typically designated through advance directives. Advance directives include a living will, which outlines the patient’s wishes for future medical care, and a healthcare proxy, which names the person authorized to make decisions on their behalf. The healthcare team is legally and ethically bound to honor the instructions of a previously competent patient documented in an advance directive. If no formal document exists, the surrogate is usually determined by state law, often starting with a spouse or adult child. Their decision must reflect the patient’s best interests or previously expressed values.
Clinical Situations Supporting Withdrawal
While a patient with capacity may withdraw treatment for any reason, specific medical contexts exist where stopping dialysis is often considered or recommended by the healthcare team. One context is medical futility, which occurs when dialysis can no longer achieve its therapeutic goals, such as prolonging life or improving functional status. In these cases, dialysis only prolongs the dying process rather than extending meaningful life.
Another clinical reason is a severe and irreversible decline in the patient’s quality of life or functional status. This includes conditions like profound neurological impairment, a persistent vegetative state, or advanced dementia where the patient cannot cooperate with treatment. The burden of the treatment itself can also become unbearable, such as repeated hospitalizations, severe pain, or complications that cause suffering. In these situations, the goal of care shifts from maximizing survival to maximizing comfort.
Navigating the Withdrawal Process
Once the decision to stop dialysis is made, the process is a planned transition, not an abrupt abandonment of care. It requires a multidisciplinary team approach to ensure the patient’s physical and emotional needs are met. This team typically includes the nephrologist, nurses, a social worker, and palliative care specialists. The social worker and palliative care team are frequently involved non-physician team members.
The team’s primary role is to ensure the decision is fully informed, voluntary, and consistently documented. A clear plan for the discontinuation of treatment is established, addressing the patient’s immediate comfort and care setting. A review of all other life-sustaining medical orders is necessary, including updating the patient’s Do Not Resuscitate (DNR) status to align with the goal of comfort care. The process is designed to provide support for the patient and family through shared decision-making, ensuring a dignified transition.
Palliative Care After Stopping Treatment
Stopping dialysis initiates an immediate shift to comfort care, also known as palliative care or hospice. The focus changes from filtering the blood to managing the symptoms that arise from the buildup of toxins and fluid, a condition called uremia. Hospice services specialize in this end-of-life care and are effective in controlling discomfort.
The symptoms to be managed are predictable and may include confusion, agitation, pain, shortness of breath, nausea, and severe itching. Medications are carefully chosen and dosed, as drugs previously cleared by the kidneys or dialysis (such as morphine or gabapentin) can rapidly accumulate and cause toxicity. The expected physiological sequence is a gradual decline, with patients typically becoming drowsy and then slipping into a coma before death. For most patients who stop dialysis, the average life expectancy is approximately 7 to 14 days, though those with residual kidney function may survive for several weeks. The primary goal during this time is to ensure the patient is pain-free and comfortable.