WITHDRAWAL OF RENAL REPLACEMENT THERAPY IN NEWCASTLE-UPON-TYNE - 1964-1993

Background. Termination of renal replacement therapy (RRT) is common i n North America and Australia but is considered to be rare in Europe. Methods. In order to review the phenomenon of RRT termination in all p atients treated in Newcastle upon Tyne between 1964 and 1993 a retrosp ective study of clinical case notes was undertaken. In all RRT patient s sex, age at start of RRT, renal diagnosis and history of RRT were re corded. In addition, mortality data and marital and residential status were recorded in all patients who died, and Karnofsky index, bodyweig ht, complications, history of bereavement, place of death, overall sur vival, survival after withdrawal of treatment, other medical problems, higher mental function and surgical history in all patients stopping treatment. Results. 1639 patients started RRT between 1964 and Septemb er 1993 inclusive. Eighty-eight patients were identified in whom death was a result of treatment being stopped (17% of all deaths), The firs t was in 1985. In these patients, age was greater (62 vs 47 years, P<0 .001) and diabetes was more prevalent(15 vs 7%, P<0.03) than in the to tal RRT population. The Karnofsky index was 70 at the start and 33 at withdrawal of treatment (P<0.001). The Karnofsky index at the start of RRT was weakly related to that at withdrawal and overall survival (r= 0.36 and 0.28 respectively, P<0.01). The Karnofsky index at treatment withdrawal correlated with the following survival (r=0.40, P<0.001). T he median survival of patients stopping treatment was significantly lo wer than in all RRT patients (16 vs 74 months, P<0.001) and the majori ty survived less than 2 years. After dialysis withdrawal the median su rvival was 8 days, 15 patients survived 3 days or less and 19 more tha n 10 days. The majority (80%) received terminal care in hospital. At t reatment withdrawal 11 patients were demented and 34 showed signs of e arly dementia. Seventy-eight patients (89%) stopped treatment as a con sequence of multiple medical problems. The possibility of dialysis wit hdrawal was raised by physicians in 50.5%, the patient in 23.8% and th e patients' relatives in 21.9% of cases. Four patients (3.8%) committe d suicide. Conclusions. Death from dialysis termination is a relativel y common cause of death in RRT patients in Newcastle upon Tyne. These patients are older with a higher prevalence of diabetes. In 89% of cas es the decision to stop treatment was related to multiple medical prob lems with a recent deterioration. Physicians raised the issue of withd rawal in the majority of cases and most patients subsequently received terminal care in hospital.