Is Quitting Dialysis Suicide

[brenda]

I worry about the pain, how awful a person would feel. I know sometimes I feel not too perky on my long stretches. So I just fear how I would feel and how long it would go on. But I do feel if and when I ever come to that point I won't want to feel like a burden to my family. I've always been very independent and just can't see myself being comfortable with someone having to take care of me. Which would probably be one of my kids. I think it's just a very individual choice. Not suicide.

[glitter]

As just a caregiver and not a patient...this whole subject fills me with dread.I didn't realize I felt that way until reading all this debate.
As a person who loves a dialysis patient-I don't ever want him to choose to leave me.(I know-selfish of me) that being said-I hope I would have enough compassion to let him go-IF he was suffering and his quaility of life was compromised.
  But as a caregiver-I have not liked facing this thread,or lost sheeps choice,and I am not sure a non-dialysis patient can really understand. Is it suicide? Is it a natural passing? I don't think I care-I just don't want him to go.

[Joe Paul]

In short, for me to accept death would be to accept defeat , sorry it ain't in me.

It would be for me, too, Joe Paul.  I agree with you.

But I know not everyone feels that way, and, if someone else felt that they had done everything they could and they wanted to stop dialysis, I would defend their right to stop dialysis without calling it suicide.

I just think everyone has the right to evaluate their own circumstances and make their own decision.  Some of us are stronger than others, and so maybe we would have made different decisions.  But, at the end of the day, we all get to make that decision ourselves.  I just hope that anyone who is considering making a decision like that will talk to everyone in their life that matters to them, it's a huge decision that affects a lot of people, not just the person stopping dialysis.

You are correct...this is how I feel at this point of my life. Keep in mind, Ive only been in clinic now, will be a year in April. Who knows how I will feel years from now, thing is I'M LIVING for today, 1 day at a time.

[jbeany]

I don't think you can give a one-size-fits-all answer to this question.  Whether or not it is suicide depends on the reasons an individual person has for quitting.  It's a matter of attitude, I think.  If you are depressed, and overwhelmed and you decide to stop so you don't have to deal with the emotional strain anymore, then it does seem suicidal to me.  If you are quitting for reasons like the ones kenvo's friends gave, where there are other medical complications, and continuing to have dialysis will only add more suffering to a life that is going to be ended very soon anyhow, I can't see that as suicidal.

Suicide is a very loaded word for so many people - it's hard for those with a religious upbring to see past the concept of "it's a sin" . 

[angela515]

I must say that in my opinion stopping dialysis IS suicide.  Whether it is wrong or right is another matter.  That is not for me to decide.  If I dive under water and stay there, nature takes its course and I drown.  Isn't that suicide? 
The definition of 'suicide' from Dictionary.com is "The act or an instance of intentionally killing oneself".  It doesn't state whether it was someone on a machine or not.
If someone stops us from going to dialysis and we die, isn't it murder?

Sopping dialysis is not suicide. In fact, there is no one who can force you to even start it. You could let nature take its course right when diagnosed from the begining. Some people feel horrible on dialysis, and why should they have to do it? To make others happy? No.

[meadowlandsnj]

My father had a friend who was 60 and diabetic, he knew his kidneys where failing and he decided not to have dialysis. Is this suicide?

Years ago one of my distant relatives (an aunt-in laws second husband) got very sick and needed to go on dialysis.  He refused it and died three weeks later.  Everyone was all upset about it, how could he do this, so on and so on.  THis was even before I got sick and knew what dialysis even was.  He was a big, huge guy and he was a professional wrestler for years.  He was in his 40's at the time of his death and he just wanted to let go of his life.  He left behind a wife, they had no kids.  I remember the family being all upset and fighting about it, if he did the right thing or did his dying mean he commited suicide. 

Donna

[Bajanne]

Isn't this debate interesting?  My dad at 89 wanted to live - he still had things inside he wanted to say to our nation; he wanted to see my daughter become a woman.  But he was refused dialysis because of his age.  By the way, apart from the kidney failure, he was a very healthy man.  No Alzheimers, no other health problems.  Our family doctor cried when he realized they would not allow my father dialysis. My father at 89 who had achieved much in my country, as an educator, as a minister of the gospel, as a farmer, who raised children who have made names for themself in our country and abroad, still felt he had something to live for. And to think that someone under 40 would consider they had achieved enough to consider giving up!
I do not like dialysis, but I am eternally grateful that I can continue to teach and see my daughter and grandson develop. 
And dialysis also brought me some special friends - right, Goofynina?

[angela515]

Wow, I never heard of anyone being refused dialysis because of their age. Could he have moved to the USA, where he wouldnt be denied?

[Sluff]

All I know is if Angela515 would have given up on dialysis, she wouldn't have recieved her new kidney last week.

[Bajanne]

Wow, I never heard of anyone being refused dialysis because of their age. Could he have moved to the USA, where he wouldnt be denied?

That is still the policy in Britain and in some other countries.  I know of a family friend in London who was sent home to die, and a man I considered quite young, just under 70, who was also taken off, in my country and subsequently died.  I am told that it was like that in the US too, many years ago. 
[Would you guys have liked another illegal immigrant in your system?]

[angela515]

I didnt mean that he would come illegally, I meant go through the system the correct way.

[Bajanne]

I didnt mean that he would come illegally, I meant go through the system the correct way.

I was just kidding really.   He did have a visa, and some of his children are American citizens, so I suppose that could have been one way, but by the time we understood how serious it was, it was a bit late.  We even offered to buy a dialysis machine, but they would still have had to run it, so they said no.

[stauffenberg]

In every country the medical system tries to discourage patients from initiating dialysis if, because of extreme age, senility, dementia, or serious co-morbidities they are not likely to do well or to profit from the extension of their life.  To my knowledge, however, there is no official policy in Britain, Germany, or Canada, three countries outside of the U.S. where I have had personal experience of dialysis, to forbid dialysis to anyone who really wants it.  When I was on dialysis in England from 1996 to 1997, and then again briefly in 1998, I saw some extremely old patients, some totally senile, with many co-morbidities, and no one was questioning their right to contrinue on dialysis.

However, I once read in a public library in Britain in 1991 a pamphlet, published in 1982, for patients about to begin dialysis.  I was struck by the comment that "dialysis is not forever; the patient should select some up-coming goal, like living to see the grandchildren marry or finish university, and plan to continue dialysis only until that goal is reached."  That was not the policy by the 1990s, however.

[Epoman]

Wow, I never heard of anyone being refused dialysis because of their age. Could he have moved to the USA, where he wouldnt be denied?

At one point in time in the USA, people were indeed refused dialysis because of their age. The term "Death Squads" ring a bell.

- Epoman

[jollor]

If someone wants to end there medical treatment then thats there decision. I don't see anything wrong with that. An I gotta say If when I'm an old man and have other heatlh problems that lead to a poor quality of life I would think of stopping treatment too.

[mrhecht]

I think there is no "one size fits all" answer to this question. I see patients so elderly, confused and sick while on treatment, that it appears they are being tortured rather than dialyzed. What is the answer for them when it has been determined that they are "no longer capable" of making their own medical decisions? Life support is life support, whether it is a dialysis machine or a ventilator, the only difference may be the amount of time required for life's end after discontinuation of life support. To ask if it is wrong to end your life support, mustn't you also ask if there is still a quality of life and by whose definition? By the family? By the patient? To ask if it is wrong to end your life (or life support) is usually closely related to your faith, or lack thereof, in God. Are you making a decision that should only be made by Him? If someone who had success, health, love, and family chose to end their life because of a mental illness, is that "wrong"? Would he be condemned because his mind was sick rather than his body? Extreme physical pain or extreme mental pain; is there a difference in the "rightness" or "wrongness" of ending your life? I believe that God would not condemn a person for ending their life because of the effects of illness, whether it is physical or mental. And when you ask if suicide is "wrong" isn't that the real question? Is it wrong by the moral standards of our society which are based on the Judeo-Christian belief in God?

[renal30yrs]

When I was very young I certain considered that option.  The thought comes across mind occasionally.

[okarol]

Another interesting poll

[Hemodoc]

As a physician who has participated in withdrawal of care in a number of patients and even one that I recall that had ESRD, it is a quite settled issue medically, legally and ethically.  It is the right of the patient to withdraw from medical care even when it a very appropriate and needed care for sustenance of life. 

Is stopping dialysis suicide?  The short answer is no.  Yet, the caveat to that is that one of the duties of a physician in this situation is to determine first that the patient is not suicidal and that is why the request was made by the patient.  Thus, often, the patient in this situation will have an examination by a psychiatrist.  Any hint of suicidal ideation places the request null and void and in fact, the medical team in this situation must administer the treatment until a time is deemed that the patient is not suicidal.  Yes, as you can imagine, this in some cases can be quite difficult.  However, in most cases, the patient no longer wishes to endure what ever treatment it is and simply wishes to let the underlying disease take its course and they are almost uniformly granted this option.

So, yes, it is true that medically, legally and ethically, it is not suicide to withdraw any medical treatment, yet it is imposed upon the practice and duty of the physician to first exclude suicide as the underlying motive.  For a medical team to continue a treatment against a patient's wishes, here in California a psychiatrist or psyche nurse must declare that the patient has suicidal ideation and is therefore a danger to himself or others.  Without this determination, yes, a patient may withdraw, withhold or refuse any and all medical treatments.  In fact, without the patients informed consent, I am not allowed to perform any treatments or examinations upon any patient.  Under our laws, the patient is the one in control whether the reality of practice actually allows the patients to truly control their own treatments.

Peter

Peter

[stauffenberg]

While I agree with you that the medical profession and the law, and even some Jesuitical reasoning by religious theorists, decides quite artificially decide not to "call" stopping dialysis suicide, there is no ethical consensus on this, since it is always open to philosophers to debate this issue as they will and ethics no conventions exist, as they do in law and medicine, to paper over the problem and pretend the issue is solved by playing ridiculous games with labels.

The problem in thinking about this issue logically is that people begin from the unproved assumption that committing suicide is wrong, evil, or condemned by some invisible entity in the sky, and so if voluntarily deciding to end your life by withdrawing a life-sustaining intervention is suicide, then that action, despite its reasonableness in many situations, has to be wrong.  But in fact there is nothing wrong with leaving a movie you find dull, or dropping a relationship that has turned sour, or getting out of a burning building where you have lived for a long time, nor even in ending your life if it becomes intolerable to you and there is no way to fix the problem. It is just common sense to get out of an unendurable situation, and it is a  pity, given all the unavoidable tragedies in human life, that people create an artificial tragedy for themselves by imagining that they owe some duty to some invisible force to continue living when it is no longer tolerable to the person whose life it is.

If you define suicide as any voluntary choice to set in motion a chain of events with the knowledge that it will lead to your death, then it is 100% obvious that withdrawal from dialysis is suicide.  As I have said before, if you need food, water, and air to live and decide voluntarily to go without any or all of these, then you are obvioiusly committing suicide.  So by the same reasoning, if in addition to food, water, and air, you also happen to need dialysis to continue living, it logically follows that if you decide to forego dialysis you are actively willing your own death and doing everthing required to kill yourself, as much as if you had swallowed 1.5 gms of cyanide or hanged yourself from the nearest tree.

There is no essential difference between 'artificial' and 'natural' life support, nor is there any real difference between actively killing and passively letting die when you are discussing your treatment of yourself.  Putting food and water in your mouth to continue living requires a whole complex series of actions to keep you alive by these means, and this differs only in degree but not in kind from the complex series of actions to keep yourself alive by attaching yourself to a dialysis machine.  But are equally 'artificial' interventions to keep yourself going, and stopping either should be called what it is: suicide.

[Hemodoc]

Dear Stauffenberg,

This is a quite interesting topic that I would have to disagree on your point that there is no consensus.  Once again, withdrawal of medical care by a patient is the right by virtue of the ethics of autonomy. In such, the entire medical field, judiciary and ethics are quite satisfied and in agreement with this and I have once again personally been involved in many such cases where autonomy and substitued judgement were invoked on patient care decisions.  Nevertheless, let's take a look at it and use your definition.  Please correct me if I don't properly represent your position.

I have on more than one occasion been involved in the care of a patient in the ICU on full life support for severe COPD where the patient is no longer able to live on their own without a mechanical ventilator.  In the situation where we are not able to wean the patient from the ventilator, we have two options.  First, place a tracheostomy and send the patient to a special nursing home for patients on ventilators.  Or, secondly, we may withdraw care and extubate or take the patient off of the ventilator.  In this case, we place the patient on a morphine drip.  Now, the patient or family make the choice to remove the ventilator.  Then I write an order for the morphine drip.  The morphine in this situation actually has the effect of relieving the suffering feeling of suffocating.  It is giving for that relief only.

Now, according to your definition, we not only have an act of removing the machine and the endotracheal tube, but I have now likewise placed the patient on a medicine that may actually hasten the death of the patient.  (This is actually a situation that I have been involved with several times and I have in reality written those very orders.) Now accorcing to your definition of suicide, I am now guilty of murder as well?

The answer once again is no.  My intent was to relieve suffering, and my intent was not to kill or murder the patient.   I do understand your point on ending dailysis and why some may construe that to be a suicide, but the consensus amongst the medical profession, the ethics establishment and most importantly among the judiciary is that I have not committed murder,  nor has this patient committed suicide.  There is a right to autonomy recognized in most western nations.  You have the right to self determine your medical treatments including the legal, ethical and medical right to refuse or remove life sustaining treatment.  Having participated in many like situations, I must most respectfully disagree that there is not a consensus on this issue as you contend.   Any patient determined to have suicidal ideation will not be allowed to withdraw life sustaining medical treatments.  This is the law, the ethics and the fudiciary duty of a physician to their patients.  Any physician that does NOT exclude suicide in this circumstance is potentially subject to criminal and medical board investigations and prosecutions. 

Most respectfully,

Peter

[stauffenberg]

There is never a consensus about anything in philosophy, which includes ethics as one of its sub-specialties, and even if there were, it would be utterly insignificant, since philosophy is not a public institution with the power to lay down official consensus conclusions, nor is it a society governed by majority rule.  Rather, it is a system of OPEN inquiry which always remains open, so no one has the right to lay down the law to it and say, "This is the consensus." 

In any case, the consensus in medicine and law about all these issues is utterly trivial and pointless, since it is only a consensus about HOW TO USE A WORD, which is not a consensus about the real, substantive issue involved, which is whether deliberately disconnecting yourself from the machine that is necessary to keep yourself alive amounts to killing yourself.

For decades the suicide rate has been undercounted because coroners bend over backwards to find excuses not to have to label an act as a self-killing.  Medicine simplifies the many cases where patients lives are deliberately shortened or ended by active or passive responses to life threatening situations by just tinkering with the semantics and CALLING some things "passive euthanasia," "do not resuscitate orders," "withholding treatment," etc., even though in fact these are killings.

The basic axiom of the criminal law is that motive does not matter: otherwise Robin Hood and others like him would go free for having a benign intent in stealing.  All that matters for determining criminality is the commission of the criminal act and the intent to commit the criminal act, which is defined as the intent to bring about the natural consequences of the act.  Since the required intent for homicide is to cause someone else's death, and the natural consequence of discontinuing dialysis is death, to intend to withdraw oneself from dialysis is to intend one's death and so to commit homicide in the eyes of the law.  Luckily for modern dialysis patients, suicide is no longer punishable as a crime, as used to be the case (only attempts to commit the crime could actually be punished, of course, though the estates of those who killed themselves used to be confiscated), since otherwise those withdrawing from dialysis could certainly be prosecuted for self-murder under the old statutes.

[Hemodoc]

Fair enough,

I will simply and respectfully agree to disagree with your own consensus on this issue.

May God bless,

Peter

[lola]

no

[okarol]

article considers the one in five Americans who chooses to stop dialysis

Caroline Cassels

Medscape Medical News 2005. © 2005 Medscape http://www.medscape.com/viewarticle/538855

Nov 3, 2005

New York, NY - A feature article in the November 3, 2005 issue of the Wall Street Journal reports that one in five dialysis patients opts to discontinue their treatment in favor of death and examines this decision through the experience of one such patient, Joe Mole [1]. Mole, a 42-year-old carpenter, stopped treatment in 2003 after four years on dialysis.

"Between 1995 and 1999, about 36,000 people died this way, government statistics show," WSJ staff reporter Michael J McCarthy writes. "Between 2001 and 2002, the latest data available, an additional 25,000 had died; the mean age of those who chose to quit dialysis was 74. The number is likely to keep growing because more people are receiving dialysis," McCarthy notes.

From 1988 to 2003, the number of Americans receiving dialysis nearly doubled, to 325,000, with another 100,000 starting treatment every year. This increase, writes McCarthy, is largely fueled by the corresponding rise in the incidence of diabetes and its subsequent negative impact on kidney function.

Of sound mind...

McCarthy reports that psychiatric research shows patients who choose to discontinue treatment are generally of sound mind and not suicidal. They typically cite "the discomfort and tedium of treatments, nausea, vomiting, exhaustion, and troubles with veins. They usually have chronic, but not terminal, health problems such as diabetes, hypertension, and heart disease," he writes.

"They don't leave family members to confront a sudden loss with little more than a suicide note. Rather, they sometimes quit treatments despite having family and friends who plead with them to choose life," reports McCarthy.

Such was the case with Mole, a type 1 diabetic who suffered a variety of complications, including amputation, impaired vision, and, finally, renal failure requiring hemodialysis.

McCarthy chronicles Mole's daily struggle with these complications, the factors that ultimately led him to decide to stop treatment and the impact this had on his family, friends, and church.

"One night in January 2003, Mr Mole lay on his bed with his sister, Ms Kimble, at his bedside. 'I can't take it any more,' she says he told her. 'I'm just too sick.' "

      
Source

   1. McCarthy MJ. Years on dialysis brought Joe Mole to a crossroads. Wall Street Journal; November 3, 2005:A1. Available at: http://ihatedialysis.com/forum/index.php?topic=2037.0