Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice

Abstract

Dialysis withdrawal has become an accepted treatment option for patients with kidney failure and is one of the leading causes of death in patients receiving dialysis in high-income countries. Despite its increasing acceptance, dialysis withdrawal currently lacks a clear, consistent definition. The processes and outcomes of dialysis withdrawal have wide temporal and geographical variability, attributed to dialysis patient selection, influence from cultural, religious and spiritual beliefs, and availability of kidney replacement therapy and conservative kidney management. As a complex, evolving process, dialysis withdrawal poses an enormous challenge for clinicians and healthcare teams with various limitations precluding a peaceful and smooth transition between active dialysis and end-of-life care. In this review, we examine the current definitions of dialysis withdrawal, the temporal and geographical patterns of dialysis withdrawal, international barriers in the decision-making process (including dialysis withdrawal during the COVID-19 pandemic), and gaps in the current dialysis withdrawal recommendations for clinical consideration and future studies.

The explorations of the awareness, contemplation, self-Efficacy, and readiness of advance care planning, and its predictors in Taiwanese patients while receiving hemodialysis treatment

“…Nowadays, medical advancements and improved care for patients undergoing haemodialysis (HD) has led to the adjusted mortality rate decreasing from 192.9/1000 patient-years to 164.6/1000 patient-years; however, the overall mortality rate of patients undergoing HD was 2-2.5 times more than patients with myocardial infarction and cancer [11]. Additionally, up to 30% of dialysis patients in high income countries across North America, Western Europe, and Oceania die from dialysis withdrawal [12]. Thus, patients undergoing dialysis are more likely to encounter ethical and legal concerns related to palliative care and advance care planning (ACP), which involves advance directives (AD), health care agents, and medical decisions for end-of-life (EOL) (i.e., timing of dialysis withdraw, do not resuscitate (DNR) orders and physician orders for life-sustaining treatment).…”

Psychosocial Aspects in Hemodialysis

“…In Western countries, the incidence of withdrawal from dialysis prior to death ranges from 20-30% [8,[111][112][113]. In North America, the incidence of withdrawal from dialysis accounts for 30% of deaths before death [114]. The decision to discontinue dialysis is associated with several factors, such as older age, female gender, white race, and clinical complications [115][116][117][118].…”

“…The psychosocial risk factors that could be associated with increased odds of withdrawal from dialysis are depression, low socioeconomic status, and dementia [39,110,117,119]. Furthermore, the most common reasons for considering dialysis withdrawal in many cases are a lack of enjoyment in life, a sense of being a burden on others, a shift in roles, a loss of control, and lack of social support [114]. Also, studies suggest that high symptom burden, such as pain, is associated with withdrawal from dialysis [114,120].…”

“…Furthermore, the most common reasons for considering dialysis withdrawal in many cases are a lack of enjoyment in life, a sense of being a burden on others, a shift in roles, a loss of control, and lack of social support [114]. Also, studies suggest that high symptom burden, such as pain, is associated with withdrawal from dialysis [114,120]. There are several obstacles in the process of withdrawal from dialysis that relate to patient and family preferences, cultural and religious views, ethical and legal issues, and priorities in policymaking [114].…”

“…Also, studies suggest that high symptom burden, such as pain, is associated with withdrawal from dialysis [114,120]. There are several obstacles in the process of withdrawal from dialysis that relate to patient and family preferences, cultural and religious views, ethical and legal issues, and priorities in policymaking [114].…”