Dialysis is not curative, and there has long been concern over its liberal provision. When acting as a bridge therapy to transplant the value is clear. However, organ shortages mean clinicians recommend for dialysis patients with no realistic prospect of a kidney transplant.
Things get more unclear when patients lack capacity to consent. When dialysis’ benefits are unclear it is difficult to conclude the course of action in the best interests of an incapacitated patient. If physicians are predisposed to dialysis as the default for patients with renal failure, discarding conservative care, cognitively impaired patients may receive unsuitable treatment as a result of clinician bias.
There are myriad reasons to deem dialysis not in the best interests of a mentally incapacitated patient, mostly relating to quality of life. For certain patients, such as those who are elderly and have dementia alongside several co-morbidities, it may not even be life-extending. Then there is the issue of the burden on the patient’s family/carer(s), which itself raises the important question of whether it is ethically justified to account for this.
This project employs an empirical bioethics approach of reflexive balancing. Interviews with patients, families, and healthcare staff provide necessary insight, enabling consideration of when it is and is not appropriate for a permanently cognitively impaired patient with ESKD to begin dialysis. The resulting moral framework will be able to assist nephrologists in such decisions, minimising any mistreatment of renal patients lacking capacity.