title: Dying on dialysis: the case for a dignified withdrawal.
abstract: Acceleration of comorbid illness in patients undergoing long-term maintenance hemodialysis may be manifested by clinical deterioration that is subtle and not immediately life-threatening. Nonetheless, it is emotionally debilitating for patients and families in addition to being medically and ethically challenging for treating nephrologists. A marked decline in clinical status warrants review of the balance of benefits to burdens dialysis is providing to a given patient and should trigger conversation about the option of withdrawal using an individualized patient-centered, rather than disease-oriented, approach. This paper presents a rationale for and an objective approach to initiating and managing dialysis withdrawal for patients who wish to withdraw because of unsatisfactory quality of life and those (many with significant cognitive impairment) for whom withdrawal is deemed appropriate because the burdens of continuing treatment substantially outweigh the benefits.
authors: Sections of Nephrology and, †Supportive Care, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia.
authors: Rebecca J
authors: RJ
authors: Schmidt
authors: Alvin H
authors: AH
authors: Moss
mesh_terms: D032722:Advance Care Planning; D000368:Aged; D015897:Comorbidity; D017281:Cost of Illness; D018450:Disease Progression; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D010166:Palliative Care; D028723:Personhood; D011788:Quality of Life; D006435:Renal Dialysis / Q000009:adverse effects*; D012297:Right to Die; D013727:Terminal Care; D013997:Time Factors; D016896:Treatment Outcome; D028761:Withholding Treatment
references: Am J Kidney Dis. 1999 Apr;33(4):688-93
references: 10196010
references: Clin J Am Soc Nephrol. 2013 Oct;8(10):1783-90
references: 23744000
references: Clin J Am Soc Nephrol. 2010 Jan;5(1):72-9
references: 19965531
references: Ann Intern Med. 1999 May 18;130(10):825-8
references: 10366372
references: Clin J Am Soc Nephrol. 2010 Feb;5(2):195-204
references: 20089488
references: J Am Soc Nephrol. 2006 Nov;17(11):3198-203
references: 16988057
references: Gerontologist. 2004 Dec;44(6):731-8
references: 15611209
references: Gen Hosp Psychiatry. 1996 Jan;18(1):8-13
references: 8666216
references: Clin J Am Soc Nephrol. 2012 Jun;7(6):1033-8
references: 22461536
references: Neurology. 2006 Jul 25;67(2):216-23
references: 16864811
references: N Engl J Med. 2013 Mar 28;368(13):1173-5
references: 23465068
references: Clin J Am Soc Nephrol. 2012 Dec;7(12):2049-57
references: 22997341
references: Am J Kidney Dis. 2003 Oct;42(4):813-20
references: 14520633
references: JAMA. 2008 Oct 8;300(14):1665-73
references: 18840840
references: J Pain Symptom Manage. 2013 Jan;45(1):104-13
references: 22841410
references: Mayo Clin Proc. 2011 Jun;86(6):493-500
references: 21628614
references: N Engl J Med. 2009 Oct 15;361(16):1539-47
references: 19828531
references: N Engl J Med. 2012 Mar 1;366(9):780-1
references: 22375967
references: J Am Geriatr Soc. 2011 Feb;59(2):304-8
references: 21275929
references: J Pain Symptom Manage. 2010 Feb;39(2):211-8
references: 19963337
references: Am J Kidney Dis. 2007 Jan;49(1):27-36
references: 17185143
references: Semin Respir Crit Care Med. 2012 Aug;33(4):362-9
references: 22875382
references: Clin J Am Soc Nephrol. 2006 Nov;1(6):1248-55
references: 17699355
references: JAMA. 2010 Jul 14;304(2):180-6
references: 20628131
references: Adv Chronic Kidney Dis. 2007 Oct;14(4):402-8
references: 17904507
references: Am J Kidney Dis. 2012 Feb;59(2):293-302
references: 22189037
references: Arch Intern Med. 2012 Apr 23;172(8):661-3; discussion 663-4
references: 22529233
references: N Engl J Med. 2013 Jan 31;368(5):481
references: 23373069
references: Nephrol Dial Transplant. 2007 Jul;22(7):1955-62
references: 17412702
references: JAMA Intern Med. 2013 Jul 8;173(13):1206-14
references: 23712681
references: J Psychosom Res. 2002 Oct;53(4):951-6
references: 12377308
references: J Am Geriatr Soc. 2011 Nov;59(11):2091-9
references: 22092007
references: Clin J Am Soc Nephrol. 2008 Sep;3(5):1379-84
references: 18596118
references: Am J Kidney Dis. 2012 Apr;59(4):495-503
references: 22221483
references: Nephrol Dial Transplant. 2003 Jul;18(7):1345-52
references: 12808172
references: Int J Psychiatry Med. 1997;27(1):71-80
references: 9565715