IM10.23-24 | Renal Replacement Therapy Ethics and Quality of Life — Summary & Reflection

KEY TAKEAWAYS

RRT ethical decision points: Pre-dialysis counselling (G4), modality selection, transplant candidacy, withholding/withdrawing dialysis, conservative kidney management, and resource allocation — each requiring bioethical reasoning and patient-centred communication.

Four principles applied to RRT: Autonomy (capacitous adult's right to refuse dialysis — legal under Indian law); Beneficence (recommend modality best aligned with patient's life goals, including CKM for appropriate patients); Non-maleficence (avoid treatments that prolong dying without meaningful QoL benefit; recognise medical futility); Justice (equitable access; NOTTO allocation criteria; prohibition on commercial organ trade).

THOA (India) framework: Living-related donation → hospital medical board approval; Living-unrelated donation → state Authorisation Committee (investigates relationship, excludes commercial motivation); Deceased-donor donation → brain stem death certification (2 physicians, not transplant team) → ZTCC allocation → next-of-kin consent; Commercial organ dealing = criminal offence.

QoL in CKD: Affects physical (fatigue, pruritus, neuropathy), psychological (depression 20–30%, anxiety), social (employment, family, caregiver burden), and existential dimensions. Screen at every visit using targeted questions; involve social work, palliative care, psychiatry as appropriate.

Withdrawing dialysis: Honour capacitous patient's refusal after: excluding treatable depression/pain/financial crisis, ensuring informed consent, documenting capacity, involving palliative care. Advance care planning should be supported for all ESRD patients (legally valid in India following Common Cause, 2018 Supreme Court ruling).

REFLECT

Gopalakrishnan and Priya — the two patients from the opening hook — both have ESRD and clear preferences, but they pull in opposite directions. Gopalakrishnan is asking you to help him die well, on his own terms, without being tethered to a machine. Priya is asking you to help her live as long as possible, by any means she can access. Both requests deserve a compassionate, legally-grounded, medically-honest response. For Gopalakrishnan: his request is legitimate, lawful, and ethically supportable. Your role is to ensure he understands the consequences, that his decision is not driven by treatable suffering, and then to walk alongside him with palliative care and CKM. For Priya: her desperation is completely understandable. Your role is to provide honest information about the legal transplant pathways, the risks of commercial donation, and the reality of the deceased-donor wait time in India — and then to support her through the legitimate system. Think about what you would say in the first 5 minutes with each of them. What is the one question you would ask first? What is the one thing you must never say — the response that would shut the conversation down and leave them feeling judged or dismissed? The quality of this conversation may matter more to the patient's wellbeing than any drug you will ever prescribe.