End-of-life decision making: withdrawing from dialysis: a 12-year retrospective single centre experience from the UK

Withdrawal from dialysis is a common mode of death in patients undergoing dialysis. Anecdotally most patients have a physician-directed dialysis withdrawal (DW) following an acute medical precipitant, rather than a patient-narrated planned withdrawal as part of a collaborative end-of-life care plan. We report a 12-year retrospective experience of patients undergoing dialysis who died following DW, and suggest clinical parameters which can be used to identify patients who are able to direct their end-of-life care process.

Retrospective 12-year review of inhouse electronic and paper records.

867 patients undergoing dialysis died during the study period. 93 patients died from DW. 9 (10%) patients electively withdrew in the absence of an acute medical precipitant and 84(90%) withdrew from dialysis for medical reasons. Patients who chose to withdraw were 10 years younger at dialysis initiation and withdrawal, had greater reported sessional difficulties/intolerances (p<0.05), greater general deterioration in terms of comorbidity and physical dependency during the course of dialysis (p<0.05), were more likely to rehabilitate following an acute medical precipitant, and were more likely to reside in their own home on DW (p<0.05). All had decision-making capacity compared with 35(42%) patients who had dialysis withdrawn for medical reasons (p<0.05).

Comorbidity, physical dependence, dialysis tolerance, cognitive decline, rehabilitation post an acute medical precipitant and, place of residence are parameters which differentiate between patients who choose to withdraw from dialysis and those who have dialysis withdrawn for medical reasons. These parameters can be used to identify terminal patients on dialysis who are able to be directive in their end-of-life advanced care planning.