Mr D was a 78-year-old man with end-stage renal disease (ESRD) from diabetes and hypertensive nephrosclerosis. He had a prior history of multiple episodes of aspiration pneumonia. For the past 2 years Mr D resided in a convalescent home, where he was visited frequently by his daughter, son, and their families. Mr D was transferred from his skilled nursing facility to the university hospital with cough, fever, and hypoxia.Mr D had had diabetes for 10 years, with repeated hospitalizations for nonketotic hyperosmolar state. Comorbid disorders included vascular dementia, atrial fibrillation, chronic lymphocytic leukemia, emphysema, pleural effusion, colonic diverticulosis, and tubular adenoma. Hemodialysis was begun 30 months prior to his final admission, but he became progressively more lethargic, less verbal, and physically weaker. A formal advance directive was never completed. On several occasions Mr D's children, and both Dr A, his family practice physician, and Dr E, his nephrologist, had discussed Mr D's deteriorating condition and the treatment alternatives that were available, including cessation of dialysis. For some time the family disagreed with respect to the goals of treatment. Despite the episodic illnesses, Mr D still seemed to relish eating and clearly enjoyed visits. Nonetheless, the repeated hospitalizations and Mr D's failure to regain his baseline status after each episode weighed heavily on his children.By the time of his most recent hospitalization, he was no longer able to eat, and talk turned to a feeding tube and other invasive support. His family painfully deliberated over this course of action and finally agreed to dialysis cessation. Mr D was unable to meaningfully participate in this decision. Five days following his last session, Mr D died in the palliative care unit of the hospital.
