Deciding about dialysis

Patients and families sometimes struggle with the question of whether dialysis is "worth it." A young woman wrote recently on a website addressing dialysis patients' concerns, "My father has been on dialysis for three years, and he's 62 years old. A few days ago he said he wanted to stop going because he was 'sick of it.' We talked to him and told him that it would hurt us if he did that, but now I'm thinking that maybe I shouldn't have talked him out of it -- this isn't about me and my feelings. This is about what he has to deal with."

When would discontinuing dialysis be a reasonable and morally acceptable choice? Could discontinuing dialysis ever be tantamount to suicide?

While every person is obligated to use ordinary (or proportionate) means to preserve his or her life, no person is required to submit to a health care procedure that he or she has judged, with a free and informed conscience, to provide little hope of benefit or to impose significant risks and burdens.

Weighing benefits and burdens is at the heart of the question of starting, continuing or stopping dialysis. As the U.S. Conference of Catholic Bishops has noted: "We have a duty to preserve our life and to use it for the glory of God, but the duty to preserve life is not absolute, for we may reject life-prolonging procedures that are insufficiently beneficial or excessively burdensome. Suicide and euthanasia are never morally acceptable options."

The benefits of the commonly-used procedure known as hemodialysis (filtration of the blood) are well known: as kidney function declines, dialysis performs part of the work that healthy kidneys normally do, filtering toxins from the body. Dialysis can serve as a bridge to a kidney transplant, which can offer the patient a new lease on life. Discontinuing dialysis during complete kidney failure usually means that the patient will die in a matter of days or weeks.

The burdens of dialysis vary from patient to patient. The procedure can be time-consuming, requiring visits to a dialysis center three times a week for three to four hours at a stretch, with additional time for transportation. One can also feel washed out the next day.

Other burdens may include sharp drops in blood pressure during or after the procedure. Fainting, vomiting, nausea, muscle cramps, temporary loss of vision, irritability, and fatigue can occur. Some patients manifest abnormal heart rhythms from electrolyte imbalances, while others may experience allergic reactions or bleeding problems from the chemicals or blood-thinning medicines used during the dialysis.

Long term dialysis can cause bone and joint pain from a deposit of various proteins known as amyloid in the hands, wrists, shoulders, and neck. Cost may represent yet another burden, depending on the patient's personal finances and insurance situation.

Still other burdens may include problems with the access point made for the dialysis -- called a fistula -- which usually occurs in the arm. This is a surgical connection made under the skin between an artery and a vein, allowing needles to access blood flow for dialysis. As many as 25 percent of hospital admissions among dialysis patients are due to problems with fistula malfunction, thrombosis, infection, and access. Multiple surgeries may be required to assure that a fistula continues to function during the time it is used.

In sum, then, dialysis can prolong and save a patient's life, but can also impose significant burdens. Depending on the various side effects and problems associated with the procedure, and depending on how minimal the benefits may be in light of other medical conditions the patient may be struggling with, it can become reasonable, in some cases, to discontinue dialysis. The burdens of hemodialysis can sometimes be lessened by using a different kind of dialysis known as peritoneal dialysis, where fluid is instilled in the abdomen via a permanently positioned catheter and later drained. Peritoneal dialysis can be performed by the patient at home each night.

It's not possible with the limited information we have to draw any moral conclusions about the case of the father who is "sick of it" and wants to stop dialysis. We need further details, such as: What is the reason for his request? Is he experiencing serious complications and significant burdens from dialysis? Does he have other medical problems besides kidney failure? Is he suffering from depression, for which he could be treated?

We should never choose to bring about our own or another's death by euthanasia, suicide or other means, but we may properly recognize, on a case by case, detail-dependent basis, that at a certain point in our struggle to stay alive, procedures like dialysis may become unduly burdensome treatments that are no longer obligatory. In these cases, it's always wise to consult clergy or other moral advisors trained in these often-difficult bioethical issues.

Father Tadeusz Pacholczyk, Ph.D. earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia. See www.ncbcenter.org.

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