Decisions around dialysis withdrawal can be highly complex and challenging for patients, caregivers, and healthcare providers. There are various reasons why dialysis withdrawal may be considered, including access failure, acute medical complications, or chronic deterioration. Shared decision-making is recommended to align this decision with the patient and family’s goals, values, and preferences.¹

However, problems can arise when there is a misalignment or disagreement between what the family/patient desires and what the medical team deems medically appropriate.

In this case, we discuss a 74-year-old woman with end-stage renal failure on intermittent haemodialysis. She lacks decision-making capacity and is bedbound and dependent in her activities of daily living due to her advanced dementia. Her recent medical deterioration and lack of access has made it difficult to continue haemodialysis. Despite the medical team’s recommendation to withdraw dialysis, her main spokesperson, a close friend, does not agree and insists on pursuing further treatment. This presents an ethical dilemma - is it appropriate to persist with dialysis in this medically frail patient, at the spokesperson’s insistence, when the treatment may not be medically appropriate or beneficial given her current state?

The Jonsen’s 4 box ethical framework was used to consider the medical indications, patient preferences, quality of life, and contextual features to plan care in the patient’s best interests in the absence of decision-making capacity.

Reference

1. Davison SN, Levin A, Moss AH, Jha V, Brown EA, Brennan F, Murtagh FE, Naicker S, Germain MJ, O’Donoghue DJ, Morton RL, Obrador GT; Kidney disease: improving global outcomes. Executive summary of the KDIGO controversies conference on supportive care in chronic kidney disease: developing a roadmap to improving quality care. Kidney Int. 2015 Sep;88(3):447–59.