Changing Landscape of Dialysis Withdrawal
A blog post written by Dr. Jenny Chen, an author from our Latest Australian Research series
Treatment withdrawal is never an easy part of medicine. For most people, hospital is supposed to be a place where lives are saved, injuries are healed, and illnesses are cured. However, treatment withdrawal does the exact opposite. For chronic dialysis patients, withdrawing from dialysis means imminent death. So, why do we (nephrologists/palliative care physicians) advocate dialysis withdrawal for selected patients? The short answer is that dialysis itself is not completely harmless.
One of the principles of ethics in medicine is nonmaleficence, or do no harm. However, harm comes in different forms and shapes and can be physical, psychological, social, financial, or legal. Dialysis is designed to replicate the functions of the kidneys and to extend life expectancy in patients with kidney failure. However, such survival benefit is not as evident in elderly patients, especially ones with multiple comorbid medical conditions 1. In return, the lives of patients on dialysis are revolved around their dialysis treatment. They sacrifice a significant portion of their lives attending dialysis units three times a week or performing home dialysis daily. For some, this means extra transport time and costs to and from the dialysis unit, patient and carer stress from performing a medical procedure at home, and lifestyle and travel limitations due to availability and accessibility of dialysis. The long-term commitment to dialysis can also take a toll on marital relationships, family dynamics, and career advancement. For intermittent dialysis, the continuous, 24/7 function of the native kidneys is condensed to 12-15 hours per week with rapid blood flow between the body and the dialysis machine. As a result, frail and elderly patients may experience dizziness, lethargy, and appetite change, even on non-dialysis days. For patients on dialysis, the quality of life is greatly impacted, and various forms of harm are endured despite prolongation of life expectancy.
Dialysis withdrawal is now one of the leading causes of death in patients receiving dialysis in Australia and New Zealand2. Due to the conventional stigma, implementation of dialysis withdrawal remains poorly conducted in clinical settings. We published a review article in the journal Nephrology in July this year discussing current definitions and implementation patterns of dialysis withdrawal, barriers in the decision-making process (including dialysis withdrawal during the COVID-19 pandemic), and gaps in the current dialysis withdrawal recommendations. We also provided a theoretical pathway for dialysis withdrawal incorporating key elements of kidney supportive care, a relatively new subspecialty combining nephrology and palliative care with a strong focus on symptom management and quality of life3. As all individuals are different, it is important to tailor the dialysis withdrawal care based on the patient’s medical, psychosocial, and spiritual circumstances, while keeping in mind the legal support. It is also worth noting that dialysis withdrawal is different from voluntary assisted dying (VAD), which is now legalised across Australia and New Zealand. VAD uses an external medical treatment to terminate life, whereas dialysis withdrawal allows kidney failure to take its natural course which eventually leads to death.
Dialysis remains the ultimate treatment option for patients with kidney failure, alongside kidney transplantation. Dialysis is an excellent therapy when well-tolerated by patients. However, the risks and benefits of dialysis need to be carefully considered, and patients should be able to raise their opinions regarding the quality of life that is acceptable to them as well as triggers to consider dialysis withdrawal. It takes a brave person to openly accept death after careful consideration. When dialysis withdrawal is the preferred option, we (the healthcare providers) should support this decision and provide ongoing care to achieve this goal with dignity.
Dr. Jenny Chen
Nephrologist
Wollongong Hospital
References
1 Foote C, Kotwal S, Gallagher M, Cass A, Brown M, Jardine M. Survival outcomes of supportive care versus dialysis therapies for elderly patients with end-stage kidney disease: A systematic review and meta-analysis. Nephrology (Carlton, Vic). 2016; 21: 241-53.
2 ANZDATA Registry. 44th Report, Chapter 3: Mortality of Kidney Failure with Replacement Therapy. Adelaide, Australia: Australia and New Zealand Dialysis and Transplant Registry 2021.
3 Chen JHC, Lim WH, Howson P. Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice. Nephrology (Carlton, Vic). 2022; 27: 551-65.