Nephrology Ethics: “No Dialysis” As a Treatment Option

Abstract

Background: Renal failure in elderly patients often generates an ethical question “should dialysis be initiated?” The nephrologists are faced with the dilemma of conveying the prognosis of renal failure in elderly patients and also explain the pros and cons of offering a renal replacement therapy (RRT).Methods: We report a retrospective study conducted between 6/2001 and 6/2003 to evaluate the clinical situations where initiating RRT was considered inappropriate. All patients who opted for not initiating/withdrawal of RRT were included in the study.Results: Twenty‐four patients were included in the study. All patients were males with average age 70.7 years. 17/24 were in the intensive care unit. Complex medical illnesses with poor quality of life were the major reasons for opting out of RRT. 20/24 patients opted for not initiating RRT and 3/24 patients opted for withdrawal. 1/24 opted for a trial of RRT before taking long‐term decisions. 3/20 who opted against initiating RRT had advanced directives. 18/20 who opted for not initiating RRT died within 3 days of the need for RRT, 2/20 are alive without RRT after 6 and 4 months with estimated GFR of 14 and 12 mL/min, respectively. Patient who opted for a trial of RRT died eventually, 4 months after a prolonged bedridden stay in a nursing home. 3/3 ESRD patients died within a week after withdrawing dialysis.Conclusion: The decision to initiate RRT should be made considering the overall prognosis. A decision to not initiate or withdraw RRT is possible in critically ill patients and if taken judiciously can reduce physical and mental stress of both patient and their family members.