When Less Is More: Discontinuing Dialysis in Palliative Care and Hospice

March is Kidney Awareness Month, a time often focused on prevention, early detection, and life-sustaining treatments like dialysis. These conversations are important—and incomplete. Missing too often is space for an equally valid, deeply human decision: the decision to stop dialysis.

For many people living with advanced kidney disease, dialysis can extend life—but it can also come with significant physical burden, emotional strain, and loss of independence. As illness progresses, some patients reach a point where the question shifts from “Can we continue?” to “Should we?” Choosing to discontinue dialysis is not about giving up; it is about redefining goals, prioritizing comfort, dignity, and quality of life, and aligning medical care with what matters most to the person living it.

This Kidney Awareness Month, we want to broaden the conversation. To talk honestly about what it means to stop dialysis, how these decisions are made, what families and clinicians can expect, and why honoring this choice is an essential part of compassionate, patient-centered kidney care.

For patients living with end-stage renal disease (ESRD), dialysis often becomes a symbol of life-sustaining treatment. However, when burdens outweigh benefits, and when suffering eclipses function, the continuation of dialysis may no longer align with the patient’s goals of care. As palliative care and hospice professionals, we are called to support patients and families through these crossroads—balancing medical insight, ethical guidance, and emotional presence.

When Is Dialysis No Longer Indicated?

There is no single rule that determines when dialysis should be stopped, but several clinical and ethical criteria guide this decision. The key is to evaluate the net benefit of dialysis in the context of the patient’s overall prognosis, goals of care, symptom burden, and values.

Poor Prognosis from Non-Renal Conditions

Dialysis is not indicated when the patient’s prognosis is limited by comorbid conditions and not kidney failure itself. These include advanced cancer with limited life expectancy, end-stage dementia (e.g., FAST stage 7), advanced frailty, debility, or bedbound status (e.g., PPS ≤ 30%, KPS ≤ 40%), severe heart failure unresponsive to therapy, and progressive neurologic disease such as ALS or advanced Parkinson’s disease. In such cases, dialysis offers no meaningful survival advantage and often compounds suffering.

Inability to Tolerate Dialysis

Some patients develop complications during dialysis that cannot be mitigated, such as persistent hypotension, severe fatigue, cramping, or confusion post-dialysis, delirium or agitation during treatments, and repeated hospitalizations related to dialysis. For these individuals, the harms of treatment outweigh the benefits, and symptom-driven care becomes the priority.

Loss of Meaningful Quality of Life

Patients who express a desire to avoid further aggressive treatment, who are bedbound and dependent for all activities of daily living, or who no longer experience a meaningful existence due to cognitive or functional decline may choose to stop dialysis. Their desire to “let nature take its course” should be respected.

Patient Autonomy and Informed Refusal

Competent patients have the legal and ethical right to refuse dialysis, even if it is life-sustaining. If a patient has a clear and consistent understanding of their illness trajectory and treatment options, and they choose to discontinue dialysis, this decision must be honored. Advance directives, POLST forms, or previously documented care preferences can help guide decisions when the patient is no longer able to participate actively.

The Role of Palliative Care in Dialysis Withdrawal

Palliative care teams play a pivotal role in assessing goals of care, managing symptoms during withdrawal (e.g., dyspnea, uremia, pruritus, pain, agitation), educating families about what to expect, providing psychosocial and spiritual support, and facilitating hospice enrollment, if appropriate.

In most cases, patients who choose to discontinue dialysis survive between 7 to 10 days, depending on residual kidney function, volume status, and comorbid conditions. The focus shifts from laboratory markers to comfort, dignity, and presence.

Navigating the Conversation: A Guide for Clinicians

These discussions are among the most difficult in medicine. Here are evidence-informed and empathy-grounded strategies to guide the dialogue.

Start with Values, Not Decisions

Open the door by asking, “What matters most to you right now?” or “What are you hoping for in the time ahead?” This centers the discussion around the patient’s goals rather than medical procedures.

Be Honest, But Gentle

Use clear but compassionate language. Avoid euphemisms like “we’re going to take a break from dialysis.” Instead, say: “I’m worried that continuing dialysis may be doing more harm than good at this point. I think we should talk about what’s best for you moving forward.”

Normalize and Reframe

It can be powerful to remind patients and families that discontinuing dialysis is not “giving up,” but rather choosing comfort, dignity, and quality over quantity. “Many people in your situation decide to focus on comfort and spending time with loved ones, rather than continuing medical treatments that may not help anymore.”

Prepare Families for the Process

Explain what to expect physically and emotionally after stopping dialysis: increasing fatigue, reduced appetite, possible confusion, and—importantly—comfort-focused medications to prevent suffering. “If we stop dialysis, your body will gradually begin to shut down. You may feel more tired, sleep more, and eat less. Our team will be with you every step of the way to keep you comfortable and supported.”

Acknowledge Emotion and Stay Present

These conversations can bring tears, silence, guilt, or fear. Don’t rush to fix it. Just stay. “This is hard. It’s okay to feel overwhelmed. You’re not alone—we’ll get through this together.”

Ethical and Legal Considerations

It is ethically appropriate to stop dialysis in accordance with patient preferences, especially when it no longer provides proportional benefit. Documentation is key—note the clinical rationale, conversations with the patient/family, and involvement of ethics or palliative teams if needed. Always support patients in signing advance directives or POLST forms if not already in place.

Conclusion

Discontinuing dialysis is not a failure. It is often a courageous, thoughtful, and compassionate act that honors a patient’s values at the end of life. As palliative care professionals, our role is not to prolong life at all costs but to ensure that each day—no matter how few—is marked by comfort, dignity, and love. In those moments, less truly becomes more.

References

Renal Physicians Association & American Society of Nephrology. (2010). Shared Decision-Making in the Appropriate Initiation and Withdrawal of Dialysis: Clinical Practice Guideline. Rockville, MD. Retrieved from [https://www.kidney.org](https://www.kidney.org/sites/default/files/11-10-0331_stopdialysis.pdf)

Singh, P., Germain, M.J., Cohen, L. and Unruh, M., 2014. The elderly patient on dialysis: geriatric considerations. Nephrology Dialysis Transplantation, 29(5), pp.990-996.

Chandna, S. M., et al. (2011). Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. *Nephrology Dialysis Transplantation, 26*(5), 1608–1614. doi:10.1093/ndt/gfq630

Farrington, K. and Chambers, E.J., 2010. Death and end-of-life care in advanced kidney disease. Supportive Care for the Renal Patient, p.281.

Pagels, A.A., 2012. Living with chronic kidney disease: perceptions of illness and health-related quality of life. Karolinska Institutet (Sweden).

DHD, D.H. and Care, N.N., 2007. ANNA position statements. Nephrology Nursing Journal, 34(3), p.319.

Hussain, J.A., Flemming, K., Murtagh, F.E. and Johnson, M.J., 2015. Patient and health care professional decision-making to commence and withdraw from renal dialysis: a systematic review of qualitative research. Clinical Journal of the American Society of Nephrology, 10(7), pp.1201-1215.