WITHHOLDING AND WITHDRAWING DIALYSIS - THE ROLE OF PHYSICIAN SPECIALTY AND EDUCATION AND PATIENT FUNCTIONAL STATUS

Withholding and withdrawing dialysis are subjects of major concern to nephrologists, because both result in a significant number of end-stag e renal disease (ESRD) patient deaths, The medical literature on withh olding dialysis is extremely limited, and that on withdrawing dialysis consists mainly of retrospective studies from the 1980s, The present study was conducted to identify ways to improve dialysis decision maki ng by providing a current understanding of how decisions to withhold o r withdraw dialysis are being made and by examining whether some patie nts who might benefit from dialysis are not being referred, In 1995, 2 2 of 27 (82%) nephrologists practicing in West Virginia agreed to part icipate in a year-long prospective study in which they completed forms on each patient from whom they withheld or withdrew dialysis, Seventy -six of a random sample of 214 (36%) primary care physicians returned questionnaires describing their practice experience in 1995 with patie nts with advanced chronic renal failure, The nephrologists withdrew di alysis from 60 of 822 (7%) patients, Academic nephrologists who had re ceived education in the ethics and law of stopping dialysis withdrew i t from a greater percentage of patients than those in private practice (12% v 6%; P = 0.009), Patients who were withdrawn more often resided in nursing homes (37% v 2%; P < 0.0001). Twenty-one patients (37%) la cked decision-making capacity at the time the decision was made to wit hdraw dialysis, Advance directives were available for 13 of the 21 (62 %) patients: eight of the 10 treated by academic nephrologists and fiv e of the 11 treated by private practice nephrologists, Academic nephro logists found advance directives to be helpful in decision making to w ithdraw dialysis of incapacitated patients more often than nephrologis ts in private practice (70% v 9%; P = 0.004), Nephrologists withheld d ialysis from 25 of 357 (7%) ESRD patients compared with 42 of 193 (22% ) withheld by primary care physicians (P < 0.001), In deciding not to refer a patient for a dialysis evaluation, 25% of primary care physici ans did not consult a nephrologist; 60% cited age as a reason not to r efer, These findings suggest that dialysis decision making might be im proved by educating nephrologists about the ethics and law of withdraw ing dialysis and about how to implement successfully advance care plan ning so that advance directives will be present and helpful when decis ions need to be made for incapacitated dialysis patients, Education of primary care physicians about when to refer patients with chronic ren al failure for a dialysis evaluation might also result in more referra ls for patients who will benefit from dialysis. (C) 1998 by the Nation al Kidney Foundation, Inc.