Responding to requests for dialysis for severely demented and brain injured patients

Nephrologists, like all physicians, need to offer their patients all reasonable treatment options, but only the reasonable options. When dialysis is (or is not) a reasonable option is an important ethical issue. The justification for dialysis, like any life-sustaining treatment, is that it prolongs life for a patient who either wishes to live or, if cognitively impaired, would (in the opinion of others) likely benefit from extending their life. This article focuses on patients with advanced dementia or severe and irreversible brain injury who are no longer capable of enjoying life, and hence gain no benefit from dialysis. I present guidelines for withholding and withdrawing dialysis and offer suggestions designed to help nephrologists avoid causing harm when the patient's family demands that dialysis be performed.