No treatment

When kidney failure reaches the stage where dialysis or transplantation is required, refusing such treatment means that the patient will die. This could happen within a few days or weeks, depending on how much kidney function they still have.

A patient may decide to explore the option of refusing treatment. It is the responsibility of the medical team to counsel such patients and their families, and support them in their decision.

Some patients may decide to try dialysis for a few weeks or months. This allows them to evaluate both the good and bad sides of life on dialysis, and to make an informed choice. It may also give patients time to settle their affairs and resolve conflicts, or have time to say goodbye to family members.

Deciding not to start dialysis
There may be good medical as well as personal reasons not to dialyze. The opportunity of refusing dialysis can be a blessing in disguise for someone with an inoperable cancer, for instance.

Withdrawal from dialysis is not an uncommon cause of death in long-standing kidney patients, particularly those who are elderly.

A patient who decides not to have any treatment, or to cease treatment after it has started, will receive counseling and support. The medical team will discuss the implications of the patient's decision at length with both patient and his or her family.

The medical team will support the patient's decision as long as they are sure that it is a fully informed choice. It is a good idea for patients to let relatives and doctors know their wishes should they become unable to make the choice themselves. This could happen if the patient is unconscious following a stroke, or otherwise mentally unfit to decide.

Sometimes patients refuse treatment, but then change their mind. This is perfectly understandable and acceptable. Any patient has the right to change his or her mind at any time.

It is helpful for some patients who feel they do not want dialysis, to agree to a trial of treatment. This allows them to see what is involved before making a final decision.

The medical team will give appropriate medication to a patient who refuses treatment or decides to cease treatment. This will keep the patient comfortable until death. The team will provide support to the patient and their family throughout this time. If the patient chooses to go home to die, the renal team will also refer the patient and family to community-based agencies that will be able to provide them with support and comfort.

Informed choice
Some patients--those with Alzheimer's disease, for instance--may not be able to make an informed choice about treatment. It can be helpful if patients make their wishes known at a time when they are able to decide for themselves.

Withdrawing from treatment after transplant
While successful transplantation offers the best possible quality of life for a patient with kidney failure, it is not without risks. The powerful drugs used to prevent rejection can lead to infections and to cancers, including serious cancers such as lymphoma.

One of the treatments for lymphoma is to stop or reduce the immunosupressant drugs. In this case, the kidney will be rejected and the patient will need to go back on dialysis.

One advantage of being on dialysis is that the patient can choose when he or she has had enough, and decide to withdraw.

Other patients, who have had a long period of successful transplantation, develop an incurable condition unrelated to the drugs they are taking. One option might be to stop taking their immunosupressant and allow the kidney to fail. Then they could die from kidney failure without dialysis.

Death from kidney failure
The symptoms that may need to be controlled in the final days before death from kidney failure include nausea, muscle twitching, and breathlessness. Sometimes there is some agitation and confusion. Pain is not usually a serious problem.

If a patient wishes to die at home, specialized nursing can usually be arranged. Some hospices will admit kidney patients who have decided not to dialyze. Hospice care is designed to take into account the needs and feelings of both patients and family.

One of the benefits of remaining in the hospital is that, if the patient decides to accept dialysis after all, the facilities are close at hand.

May 1, 2006