Ethical principles and processes guiding dialysis decision-making.

When the US Congress created the End-Stage Renal Disease (ESRD) Program in 1972, it gave physicians the responsibility of determining which patients were "appropriate" for dialysis. Congress provided no guidance on who should be selected or how. Only five years later, Dr. Belding Scribner, the father of chronic dialysis, noted that there was a need for a "deselection committee" because virtually all criteria for dialysis patient selection had been slackened, if not abandoned. In 1991, the Institute of Medicine Committee to Study the Medicare ESRD Program recommended the development of a clinical practice guideline because they noted there were "an increasing number of [dialysis] patients with limited survival possibilities and relatively poor quality of life." In 2000, the Renal Physicians Association and the American Society of Nephrology heeded the Institute of Medicine committee's recommendation and published Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. In 2010, prompted by a substantial body of new research evidence, the Renal Physicians Association published a second edition of this clinical practice guideline. This article describes the application of the ethical principles of respect for patient autonomy, beneficence, nonmaleficence, justice, and professional integrity, and the ethical process of shared decision-making in making decisions about starting, withholding, continuing, and stopping dialysis with patients and families. It urges examination of medical indications and identifies appropriate limits to shared decision-making when the burdens of dialysis can be predicted to substantially outweigh the benefits.