WITHDRAWAL FROM DIALYSIS - THE ROLE OF AUTONOMY AND COMMUNITY-BASED VALUES

By examining the ethical features of dialysis withdrawal as well as tr anscultural differences in attitudes toward withdrawal, one can have a better understanding of the role of autonomy and community-based valu es on medical decision-making. Three distinctive patterns of withdrawa l are described herein. The first concerns patients suffering from an advanced state of physical or mental decline. When a patient or health care surrogate decision maker requests cessation of therapy because i t fails to be beneficent for the patient in his or her totality, the p hysician should be prepared to cooperate, in accord with beneficence a nd nonmalfeasance as well as autonomy. The second pattern occurs when the patient loses decisional capacity, and the surrogate decision make r makes unreasonable requests for nonbeneficial care. At issue is what constitutes nonmaleficence and beneficence in this setting, the provi der and surrogate differing on whether continuing dialysis constitutes beneficence. Such a dilemma can alleviated by community-based consens us guidelines with consent of the patient before losing capacity. The dialysis network is potentially a unit of patient and professional com munity. In third pattern, the patient's decision to withdraw appears t o be inappropriate to their potential for benefit from continued thera py. The nephrologist and patient are conflicted on what constitutes be neficence, with the former holding that continuation is morally superi or. In such cases, the physician must mediate the situation in a benef icent fashion not solely dictated by a constraining view of patient au tonomy. (C) 1996 by the National Kidney Foundation, Inc.