Nephrologists should be integral to the IWR-1 order decision-making and ongoing management of patients in each of these pathways. Not surprisingly, nephrologists, dialysis nurses and allied health staff, along with patients and families, are becoming less certain that dialysis will be the right choice for patients with multiple

co-morbidities, poor quality of life (QOL), poor nutrition or poor functional status. There has been renewed interest worldwide in offering an alternative to dialysis for such patients. This has come about with recognition of the expertise that Palliative Care specialists can offer in the holistic management of such patients, with a strong emphasis on symptom control. Various programmes and guidelines have been developed, predominantly in the United Kingdom and the USA, to assist nephrologists and their patients in the non-dialysis option of treatment for selected patients with ESKD. Many nephrologists have already made it part of their usual practice to offer a ‘non-dialysis’ pathway to selected patients but many are also understandably troubled when making such decisions. This issue has become

more prominent because of the increasing number of aged patients with co-morbidities, frailty, or poor functional status who present with ESKD, for whom decisions need be made as to the appropriateness of dialysis. Doctors should not offer a treatment which selleck chemicals Meloxicam they believe (with their clinical skills and knowledge) will do harm; this is a very important principle in the dialysis decision-making pathway. While this document provides a structure around the process of helping doctors, patients and their families towards either a dialysis or non-dialysis pathway through a structured consideration of likely survival, co-morbidities

and ethical principles, it cannot provide definitive answers for every case. Nephrologists will bring differing viewpoints themselves to these decision-making processes; it is usual that nephrologists begin by exploring the patient and family’s goals of management, coming to a shared decision about the appropriateness of either a dialysis or non-dialysis pathway whenever possible. The important thing this position paper stresses is the need to remain open to the option that dialysis is not always in the patient’s best interest. While having such discussions with patients and their families may be difficult and time consuming they have significant implications for patients’ future well-being. The published evidence in making these decisions for an individual patient is limited at present but this is not an ‘evidence free zone’ and this document includes hundreds of published peer reviewed references and links to guidelines from various learned societies.