Medical and Ethical Dilemmas when an Advanced Cancer Patient Discontinues Dialysis

time of onset of his hemoptysis, he was informed by physicians at an acute care hospital, were he was briefly hospitalized, that he might wish to consider stopping his dialysis in the near future. He was told he would "simply fall into a deep sleep, than a coma, and survive on average only seven to 10 days". He was now contemplating his future and possible future symptoms, and was giving serious thought to discontinuing his dialysis. He inquired into the possibility of being admitted to a local hospice, if he chose to stop his dialysis. He continued to enjoy visits with his children and grandchildren, and spending time sitting outside in his backyard. His family had indicated that, while they preferred him to continue his dialysis, they would respect his decision to stop treatment. At the time, it was felt that he had an adjustment disorder with depressed mood, rather than a major depression. Discussion was held at the time of the initial visit regarding treatment options, including referral to the cancer hospital for possible radiation therapy for his hemoptysis, as well as changing to a stronger opioid because of incomplete pain control, and signs and symptoms of neurotoxicity on codeine. He was initially reluctant to try a different opioid, but later agreed to do so because of escalating pain. Thus, two days later, he was started on hydromorphone, 1 mg orally every 6 hours. Two days later, the patient increased his hydromorphone dose to 2 mg orally every 2 hours. Within another two days, his family physician recommended a dose change to 3 mg orally every 6 hours, because the patient was becoming drowsy. A bone scan done at this time was suspicious for metastatic disease involving the T9 vertebra. A follow up visit by the Regional Palliative Care Program, two days later, determined that the patient had been experiencing increasing drowsiness and visual hallucinations. He had not used any breakthrough analgesia in the preceding 48 hours. As the patient An 82-year-old man initially underwent a left nephrectomy for a localized left renal transitional cell carcinoma. Eleven months later, he was found to have recurrent disease involving the right kidney, requiring ureteral stenting and then hemodialysis three times a week. At the same time, he was found to have pulmonary metastases. Three months following his diagnosis of disease recurrence, the Regional Palliative Care Program in Edmonton was asked to see him in consultation at home because of symptoms including a three-week history of moderate hemoptysis, left flank pain-felt to be of combined visceral and bony origin-and shortness of breath. He was then taking acetaminophen with codeine, two tablets every four hours, with incomplete pain control, drowsiness, confusion, and perceptual disturbances. One week prior to the palliative care consultation, he was described as being more emotional, occasionally tearful, and grieving over his present and impending loss of independence. He was concerned about becoming a burden to his family. He described himself as an anxious individual but, for the most part, had felt he was coping well with his cancer until recently. At the INTRODUCTION