Foregoing or Withdrawing Dialysis: Perspectives of Nephrologists

Weighing the benefits and burdens of dialysis in frail elders with chronic kidney disease (CKD) — and deciding whether to withhold this intervention — are among the most difficult discussions clinicians have with such patients and their families. In this qualitative study, researchers conducted interviews with 41 U.S. nephrologists and 18 nephrologists in England to get their perspectives on foregoing or withdrawing dialysis. The following themes emerged:

• Nephrologists from both countries noted a lack of guidelines and accurate prognostic tools to inform discussions about foregoing dialysis.

• Both groups cited default expectations (among physician colleagues and patients or families) to perform dialysis and stated that it was often “easier to initiate dialysis than to initiate difficult conversations.”

• Nephrologists in the U. S. noted financial incentives to dialyze patients, disincentives to have extended discussions with patients about foregoing dialysis, and disincentives to manage nondialytic care.

• For patients who forego dialysis, English nephrologists described better access to supportive and palliative care options than did U.S. nephrologists.

• Perspectives regarding withdrawing dialysis generally paralleled perspectives on foregoing dialysis.

• Both groups described inadequate emphasis on end-of-life issues during nephrology training.