Objective To explore decisions regarding the use renal replacement therapy (RRT) as patients approach end of life.

Background End stage renal failure (ESRF) has many potential treatment options, including RRT, renal transplantation and conservative management. Complexities exist (including the impact on quality of life and length of life) regarding the instigation or withdrawal of RRT in patients who are nearing end of life. RRT is unique as no other organ function can be as readily and effectively replaced; this alone can make it difficult for people to choose not to have treatment.

Method We reviewed three cases of patients with ESRF approaching the end of life:

Patient 1 – On renal replacement therapy, wishing to withdraw from RRT

Patient 2 – A patient with a short life expectancy due to comorbidities but who wanted to commence RRT for acute-on-chronic renal failure who developed immediate cardiac complications requiring end of life care

Patient 3 – A patient who was being conservatively managed who then developed acute-on-chronic renal failure due to an acute illness who declined RRT

The role of the multi-disciplinary team in the decision-making process, in conjunction with discussions with patients and their relatives, was also considered.

Results The three patients made different choices for the management of their renal failure as they approached end of life. They made informed decisions about their care with the support their family and the renal multi-disciplinary team.

Lessons learnt The impact of RRT on quality and length of life should be considered in patients nearing the end of their lives. Renal MDT involvement in the decision-making process is imperative to ensure the patient makes an informed decision. The three patients considered made different choices as they approached end of life reminding us of the importance of patient‘s wishes in their end of life planning.