Variation in the attitudes of dialysis unit medical directors toward decisions to withhold and withdraw dialysis.

Increasingly, physicians who treat patients with renal failure are deciding with patients and families whether to withhold or withdraw dialysis. These decisions as well as those concerning whether medical directors of dialysis units felt prepared to make them were studied using three hypothetical scenarios. A questionnaire survey of 524 physician medical directors of adult chronic dialysis units throughout the United States was conducted. They were asked about decisions to withdraw dialysis from a competent patient and a patient with severe dementia, about decisions to withhold dialysis from a permanently unconscious patient, and also about their use of ethics committees to reach these decisions. Three hundred eighteen (61%) responded. Most, 92%, indicated that their units would usually honor a competent patient's request to stop dialysis. There was less agreement about whether to start dialysis in permanently unconscious patients; 83% would withhold dialysis, and 17% would provide it. There was the least agreement about continuing dialysis in patients with dementia; 32% would stop dialysis, and 68% would continue it. Ninety-four percent of medical directors reported that they felt prepared to decide about withholding and withdrawing dialysis. Eighty percent said they might consult a Network ethics committee for difficult decisions. Almost all medical directors of dialysis units believe that they are prepared to make decisions to withhold and withdraw dialysis. Nevertheless, this study revealed significant variation in their attitudes toward these decisions. Practice guidelines and consultation with ethics committees might assist dialysis unit medical directors in making these decisions more uniformly and in a way that promotes patient benefit.