# Exploring Willingness: What Drives Dialysis Withdrawal Decisions in Patients With End-stage Renal Disease? A Cross-sectional Study

## TL;DR

This study explores why patients with end-stage kidney disease choose to stop dialysis, finding that willingness increases with disease severity and is influenced by dialysis quality, education, and palliative care knowledge.

## Contribution

The study identifies specific factors influencing dialysis withdrawal decisions across varying disease prognoses in ESRD patients.

## Key findings

- Willingness to withdraw from dialysis increases as disease worsens, though most patients still prefer to continue.
- Poor dialysis quality, lower education, and better palliative care knowledge are linked to withdrawal decisions.
- Nephrologists are seen as key influencers in withdrawal discussions, highlighting the need for early end-of-life care planning.

## Abstract

Withdrawal from dialysis in patients with end-stage renal disease (ESRD) can mitigate futile treatments and facilitate early end-of-life care preparation. However, the reasons patients willingly withdraw from elective dialysis under varying disease prognoses, and the factors that influence these decisions, remain unclear.

To explore the factors influencing the willingness to electively withdraw from dialysis in patients with ESRD at different disease prognoses.

This cross-sectional observational study was conducted in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Using convenience sampling, patients aged ≥ 45 who had regularly undergone hemodialysis for more than 6 months were recruited from a medical center and a local clinic. We used structured questionnaires and chart reviews to collect data from February to April 2021. Descriptive analysis, Pearson’s correlations, and stepwise regression were employed to assess willingness to electively withdraw from dialysis.

The 121 participants enrolled were of an average age of 61.09 years, had undergone dialysis for 7 years, and had a median of four comorbidities. Willingness to withdraw from dialysis increased as their disease worsened. However, more than half preferred to continue dialysis, with the number of patients decreasing from 76% to 53.7% across the disease deterioration trajectory. The participants identified nephrologists as the most influential individuals in their dialysis withdrawal discussions. Factors associated with dialysis withdrawal decisions across all hypothetical prognosis scenarios (current disease conditions, irreversible complications, and estimated survival < 6 mo) included poor quality of dialysis, lower educational level (junior high school), and better knowledge of palliative care.

Willingness to withdraw from dialysis is associated with dialysis quality, educational level, and palliative care knowledge under different hypothetical prognosis scenarios. Nephrologists play a pivotal role in initiating withdrawal discussions and influencing decision-making. Health care providers should consider these factors during routine renal nursing care and identify the appropriate time to initiate advanced care planning discussions. Regular monitoring of dialysis-related symptoms and quality (measured by Kt/V) and evaluating patients’ understanding of palliative care are both essential in ESRD care. As primary caregivers, nurses play a crucial role in integrating these assessments into routine care to identify patients considering dialysis withdrawal. Collaborative efforts between nurses and nephrologists are vital to initiate timely end-of-life care discussions and preparations, improve patient-centered care, and improve end-of-life outcomes in ESRD management.