Stopping dialysis of an incompetent patient over the family's objection: is it ever ethical and legal?

Decisions to stop dialysis or other life-sustaining treatments for incompetent patients are among the most difficult ethical problems faced by physicians and families. This observation is verified by the large number of court cases and the increasing frequency of ethics consultations on these issues. In such instances, in the absence of an advance directive, the usual practice for physicians is to turn to the patient's family for direction on whether to start, continue, or withdraw the treatment. They do so on the presumption that the family best represents the patient's interests. This presumption may not always be correct. A case is presented in which the family's insistence on continued dialysis was contrary to the patient's previously expressed wishes and the treating physician's assessment of the patient's best interests. It is asserted that, in such situations, after thorough conversation with the family, consultation, documentation, and an unsuccessful attempt to transfer the patient's care to another physician, nephrologists have an ethical obligation and legal right to override the family's decision and to stop dialysis. The ethical obligation is supported by the principles of respect for persons, beneficence, and nonmaleficence. The legal right is grounded in common law and state statutes.