Abstract

Three ethical principles currently determine both law and practice with respect to starting and stopping dialysis in end stage renal disease cases: Medical Futility, Respect for Life, and Patient Sel-determination. Even where dialysis is not medically futile, patients possessing capacity, and patients lacking capacity but with valid, functioning proxy decision-makers, self-determination is the dominant principle, in that efforts to prolong and preserve life may be set aside or not initiated at the request of the adequately informed patient or the patient’s proxy, both presumed conclusively to be acting in the patient’s own “best interests.” Where the patient lacks capacity and there is no proxy, Respect for Life dominates, and we are required to initiate and continue dialysis that is not medically futile, except where there is available clear and compelling evidence that the patient would not want life prolonged with dialysis, as in an advance directed or documented conversation. This category of patients — those lacking capacity who have given neither advance directives nor designated proxies — constitutes a continuum of cases. “At one extreme is the patient who will actually be harmed by dialysis — that is, the effects of dialysis will cause damage to other functions, or will cause significant increase in pain and suffering that would not occur absent the dialysis. In such situations, it can be said that [initiation of] continuation of dialysis is not medically reasonable,”i or is medically futile. The middle portion is the range of “difficult cases . . . where the therapeutic value of dialysis is..