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Perspectives on Care at the Close of Life: CODA
August 13, 2003

Practical Considerations in Dialysis Withdrawal: "To Have That Option Is a Blessing"

JAMA. 2003;290(6):815. doi:10.1001/jama.290.6.815

In April 2003, Cohen et al1 introduced Mr D, an elderly man with dementia whose family struggled to make the decision to terminate maintenance hemodialysis after 10 years. The authors suggest that cessation of life-support treatment for patients with end-stage renal disease should generally be considered when the burdens of therapy substantially outweigh its benefits. Decisions to withdraw dialysis now precede 1 in 4 deaths of patients who have end-stage renal disease. The authors recommend use of guidelines that have been recently published to assist clinicians in making these complex and emotionally charged determinations. The guideline principles include: relying on shared decision making by all participants, obtaining informed consent, estimating the prognosis on dialysis, adopting a systematic approach for conflict resolution of disagreements, honoring advance directives, and ensuring the provision of palliative care. Cohen et al discuss the stages and methods for implementing these guidelines to help physicians facilitate a comfortable and well-monitored death. Mr D's physicians took a great deal of time to help the family with their deliberations. After much discussion over several months with Mr D's primary care physician and nephrologist, the decision to cease dialysis was made. Mr D died peacefully in the terminal care unit of a hospital 5 days later, with his family nearby.