Journal Departments

Controversies in Nephrology Nursing

Withdrawal from Dialysis:
Palliative, Compassionate Care or Patient Suicide?
Christy Price Rabetoy, Department Editor

Leave the Decision to the Patient
Sue Eller, RN, CNN
Renal Care Group, Acute Dialysis
Sacred Heart Hospital
Spokane, WA
Member, ANNA’s Inland Northwest Chapter

The following question is frequently raised by health care workers, patients, and families: Does allowing discontinuation of dialysis on a terminally ill or suffering patient constitute compassionate, palliative comfort care or is it actually allowing the patient to commit suicide?

I doubt health care workers would ever be against mitigating the ravaging effects of a patient’s failing body. Care and comfort is what we provide and what we would want provided for ourselves in similar circumstances. To prolong an inevitable death with pointless suffering does not make sense.

Furthering physical, emotional, or financial stress and strain is highly questionable. Many health care workers have emphatically discussed with family and patients what their wishes are in situations of hopeless, futile care. There is no way to measure the full impact of the constant debilitating pain and suffering some patients endure. The signs and symptoms exhibited are but a poor reflection of the totality of what the patient feels and experiences.

On numerous occasions I have heard from hospital staff and co-workers, “What in the world are we doing this for?” “Don’t ever let anyone do this to me.” Modern medicine has made possible, and in some cases routine, aggressive interventions aimed at a miraculous cure. But just because we can, does not necessarily mean we should attempt all interventions. On the other hand, I do not believe that a patient choosing not to accept or to withdraw treatment is committing suicide. Each individual case is unique and must be considered for its merit. What is a meaningful quality of life for one, may be far beyond what another would care to endure or accept. I am not advocating for an inflexible rule to decide when or if to stop dialysis. I definitely do feel that we have an obligation for physical, emotional, and financial reasons to know when we are crossing the line of good faith with our patients.

The financial cost of futile, or perceived meritless care received by our patients cannot and should not be ignored. The provision of health care can not be decided solely on the financial bases, but it must be taken into consideration. We all make day to day decisions of what we can or cannot afford (i.e., medications, braces, orthodontic surgeries, a more prestigious home or car). Patients and families may also make decisions regarding the cost outweighing the burdens and benefits of continuing on the current plan of care. Discontinuing health care interventions is a decision we all should be allowed to make. Patients need to be allowed to say “I am stopping,” without the stigma of being a quitter or of having given up or having committed suicide whatever their reason may be for not initiating or withdrawing dialysis.

Is Withdrawal From Dialysis Suicide?
Ronald B. Miller, MD
Clinical Professor of Medicine, Emeritus
Founding Chief of the Renal Division
Founding Director of the Program in Medical Ethics
University of California, Irvine
Irvine, CA

To answer the question asked in the title of this essay, one must define the word, “suicide”, and one must also define the context of the withdrawal from dialysis. But first note that the question concerns “withdrawal from dialysis” by a patient, not “withdrawal of dialysis” by a physician.

Suicide, the noun, is defined in Merriam-Webster’s Collegiate Dictionary, 10th edition, as “the act or an instance of taking one’s own life voluntarily and intentionally, especially by a person of years of discretion and of sound mind.” Suicide, the verb, means “to put oneself to death.”

First, the usual context: The patient has end stage renal failure such that the patient is dialysis-dependent – i.e., would die within a month if dialysis were discontinued. The patient is aware of this, is fully informed, is not coerced by his/her family or physician, and the patient voluntarily, informedly, and intentionally decides to discontinue dialysis knowing that doing so will cause his/her death.

The reason the patient elects to discontinue life-sustaining dialysis is irrelevant to the question whether doing so is suicide. It is relevant, of course, to other questions, such as whether the patient truly has an understanding of his/her condition, its prognosis, options for treatment (here we assume the patient is not discontinuing dialysis in order to have a kidney transplant), the consequences of discontinuing dialysis, as well as whether the reason the patient gives for wishing to discontinue dialysis is rational and is not otherwise solvable.

Unfortunately, the word “suicide” has a pejorative sense – i.e., negative connotations. At the very best, taking one’s own life is seen as unfortunate, but very often it is thought to be immoral: usurping God’s right to determine when one’s life should end (from a religious perspective), or selfish and inconsiderate of those who love the individual (from a secular perspective).

Now another context (the patient has life insurance): The term “suicide” may have legal implications: For example, invalidating life insurance such that the widow or widower or named beneficiary would not receive the death benefit of the insurance policy. Thus, state law – recognizing that this would be unfair – may specifically state that withdrawal from life-sustaining treatment is not suicide. But what the law really intends is to allow the death benefit, and not really to redefine the word “suicide.” In this sense, if the context is discontinuation of dialysis by a patient with life insurance, one may wish to say that withdrawal from dialysis is not suicide even though it literally is suicide.

The limited permissible length of essays in this important point-counterpoint section or department of the Nephrology Nursing Journal is such that I will simply refer the reader to an extremely fine discussion of an extraordinary case by Robert D. Truog (Levine & Truog, 2001). In the discussion, Dr. Truog notes that both “ killing” and “allowing to die” can be morally justified, or morally not justified, depending upon the context (p. 905). He asked, “How can we accept the fact that excellent end-of-life care that involves the withdrawal of life-sustaining treatment is most accurately defined as “justifiable killing” when this term [“killing”] has such negative moral connotations?” He goes on to say, “We simply have not yet invented a vocabulary to describe the nuances of what is involved in the delivery of excellent end-of-life care. To say that withdrawal of mechanical ventilation or other forms of life-sustaining treatment is ‘allowing to die’ is factually inaccurate” (p. 906). Similarly, I must conclude that withdrawal from dialysis is suicide even though its pejorative sense and legal implications are most unfortunate.

The Controversies in Nephrology Nursing department focuses on exploring ethical and clinical issues within the nephrology clinic practice in a point/counterpoint format. Address correspondence to: Christy Price Rabetoy, Department Editor, through the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856) 256-2320; or by emailing her at christycpr@comcast.net. You may also log onto this column at www.nephrologynursingjournal.net (clink on Department link) and email your comments to the Editor (see Discussion Area). The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.