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Withholding and Withdrawing Dialysis in the Intensive Care Unit: Benefits Derived from Consulting the Renal Physicians Association/American Society of Nephrology Clinical Practice Guideline, Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis

Samir S. Patel^*, and Jean L. Holley

^* Department of Medicine, George Washington University, Washington, DC and Department of Internal Medicine, University of Illinois, Urbana-Champaign, Illinois

Correspondence: Dr. Samir Patel, Division of Renal Diseases and Hypertension, George Washington University, 2150 Pennsylvania Avenue, NW, Suite 1-200, Washington, DC 20037. Phone: 202-741-2283; Fax: 202-741-2285; E-mail: spatel{at}mfa.gwu.edu

Despite advances in the technology of dialysis, mortality in patients who develop acute renal failure remains high. Scoring systems have been developed to improve the ability to define prognosis in seriously ill patients with acute renal failure but predicting outcomes for individual patients is uncertain. Decisions to withhold or withdraw dialysis in seriously ill patients are difficult for patients, families, and health care providers. The clinical practice guideline, Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, provides evidence-based recommendations to aid nephrologists in discussions and the process of medical decision-making about starting and stopping dialysis. Estimating prognosis and addressing the issues of advance directives and patient and family preferences through the process of shared decision-making can clarify appropriate strategies for clinical management and interventions. Time-limited trials of dialysis may be an invaluable tool in this process. Increasing nephrologists’ awareness of the guideline may facilitate decision-making around the issues of withholding and withdrawing dialysis in part by clarifying patients and situations in which it may be appropriate to withhold or withdraw dialysis.