The decision to stop chronic dialysis, whether hemodialysis or peritoneal dialysis, is a deeply personal and serious medical choice for a person with end-stage kidney disease (ESKD). Dialysis is a life-sustaining treatment that performs the functions of failed kidneys, meaning that discontinuing it sets in motion a predictable process of physical decline. This choice is usually made in consultation with physicians and family when the burdens of treatment begin to outweigh the benefits or when a person’s quality of life has severely diminished. Understanding the progression of events after cessation allows for informed decision-making and planning for comfort-focused care.
Immediate Physiological Consequences of Cessation
When dialysis ceases, the body immediately loses its mechanism for removing metabolic waste products and excess fluid, leading to a rapid accumulation of toxins in the bloodstream. The most apparent consequence is the buildup of uremic toxins, such as urea and creatinine, which are normally filtered by the kidneys. This rising toxicity, known as uremia, affects nearly every organ system, including the brain, heart, and digestive tract.
Fluid overload, or hypervolemia, is another immediate result, as the body can no longer effectively excrete the water consumed through food and drink. This excess fluid quickly moves out of the bloodstream and into the tissues, causing noticeable swelling in the legs, hands, and abdomen. More dangerously, the fluid can accumulate in the lungs, leading to a condition called pulmonary edema.
The most acute threat to life comes from severe electrolyte imbalances, particularly hyperkalemia, which is an excessive level of potassium in the blood. Potassium is necessary for nerve and muscle cell function, but high concentrations disrupt the electrical signaling of the heart. As the potassium level rises, it can lead to fatal heart rhythm disturbances, or arrhythmias, causing cardiac arrest. Furthermore, the kidneys’ inability to excrete acid results in metabolic acidosis, where the blood becomes overly acidic, stressing the body’s systems.
The Progression of Symptoms and Timeline
The timeline following dialysis cessation is variable, often ranging from a few days to two or three weeks, depending on the patient’s remaining kidney function and overall health status. Patients who still produce some urine may experience a slower progression than those who are anuric, meaning they produce no urine. The initial phase is often marked by increasing fatigue.
Soon after, a person may experience gastrointestinal symptoms, including a profound loss of appetite, nausea, and vomiting. As fluid overload worsens, shortness of breath becomes a prominent and distressing symptom due to congestion in the lungs. This breathlessness is a primary focus of comfort care management.
As uremia intensifies, it begins to affect the central nervous system, leading to mid-stage symptoms such as confusion, disorientation, and delirium. This toxicity can also cause restlessness, agitation, and myoclonus, which are involuntary muscle twitches. In the final stage, the patient typically becomes progressively more drowsy and lethargic, eventually slipping into a deep sleep or coma. Death usually occurs peacefully, often resulting from a cardiac event caused by severe hyperkalemia or respiratory failure from overwhelming fluid overload.
Comfort Care and Medical Management
Following the decision to stop dialysis, the goal of care shifts entirely from life-prolonging treatment to maximizing comfort and preserving dignity. This transition involves enrolling the patient in a palliative care or hospice program, which specializes in managing symptoms at the end of life. The focus is on anticipating and aggressively treating physical distress rather than attempting to reverse the underlying kidney failure.
Medication management is crucial, with specific drugs used to target the symptoms caused by uremia and fluid imbalance. Opioids are frequently used for pain and to effectively manage the sensation of shortness of breath. Anti-nausea medications, or antiemetics, help control the vomiting and nausea associated with the rising level of toxins.
Benzodiazepines or other sedatives may be administered to reduce anxiety, restlessness, and agitation, helping to ensure a calm and peaceful final period. The care team also helps the patient and family adjust to physical changes, such as increasing drowsiness and reduced fluid intake. Specialized care ensures the patient is clean, safe, and supported until the end of life.