NUR 391 Module 3 Ethics Essay on Dialysis Withdrawal Example

"I Am Done With the Machine": An Ethical Analysis of a Request to Stop Hemodialysis

Student Name

Edson College of Nursing and Health Innovation, Arizona State University

NUR 391: Professional Nursing Theory

Instructor Name

Month Day, Year

"I Am Done With the Machine": An Ethical Analysis of a Request to Stop Hemodialysis

Few decisions in outpatient nursing carry as much weight as a patient's request to stop dialysis. The nurse is often the first to hear it, usually in the middle of a treatment, and the response in that moment can shape everything that follows. This essay analyzes a composite scenario from an outpatient hemodialysis clinic, applies four ethical principles and the American Nurses Association (2025) Code of Ethics for Nurses, and recommends nursing actions that respect the patient while protecting his safety and supporting his family.

The Scenario

Mr. R. is a 74-year-old retired copper miner who has received in-center hemodialysis three times a week for six years. His other conditions are type 2 diabetes, heart failure and a below-knee amputation. Over the past year he has been hospitalized four times, twice for fluid overload and once for an access infection, and he now needs a wheelchair to reach his chair at the clinic. During a Thursday treatment he tells his nurse, "I am done with the machine. I want to stop." He has been weighing the idea since his last hospital stay, he explains, that he is tired of spending twelve hours a week in the clinic, and that he would rather spend his remaining time at home. His daughter, who drives him to treatment, overhears and says that he is depressed and does not mean it. She asks the nurse not to tell the doctor.

The Ethical Question

The central question is whether Mr. R.'s request to stop dialysis should be honored, and what the nurse's obligations are while that question is answered. A second question is what the nurse owes his daughter, who asks the nurse to keep his request from the physician. These are not questions the nurse can decide alone, since withdrawal requires a physician's order and a planned transition to comfort care, but the nurse's actions in the first hours and days are ethically significant.

Decision-Making Capacity

Before any principle is weighed, the team has to establish whether Mr. R. is able to decide. Capacity is judged one decision at a time: the person must grasp the facts, see how they bear on his own life, weigh the options against each other, and state a choice. Clinical guidance on dialysis decisions recommends that the team assess capacity, look for treatable conditions such as depression that could distort judgment, and involve the patient and family in shared decision-making before any withdrawal (Galla, 2000). Mr. R.'s daughter raises depression, and the concern deserves attention: depression is common in people on dialysis and can be treated. However, sadness about a hard life is not the same as a disorder that impairs judgment. If an assessment finds that Mr. R. understands that stopping will lead to his death, can explain his reasons, and holds the same wish over time, his capacity is intact even if he is also grieving.

Applying Ethical Principles

The four principles commonly used in health care ethics are respect for autonomy, beneficence, nonmaleficence and justice (Beauchamp & Childress, 2019).

Autonomy

Respecting autonomy requires the team to accept a capable person's decision even when others in the room disagree with it. Dialysis is a treatment, not a requirement, and a competent adult may refuse or stop any treatment. If Mr. R. has capacity, his request carries the greatest weight in this scenario. His choice must also be an informed one, so he should hear what stopping will mean, what comfort care can offer, and what alternatives exist, such as shortening or reducing treatments.

Beneficence and Nonmaleficence

Beneficence asks what will benefit the patient, and nonmaleficence asks the team to avoid harm. Continuing dialysis would prolong Mr. R.'s life, but the benefits he values, such as time at home, are being consumed by treatment and hospitalizations. Continuing against his wishes would impose a burden he has said he cannot bear. Stopping will lead to death, which is the gravest harm, but forcing a treatment he refuses could also be a harm. Here the two principles point toward a careful, supported transition rather than a simple answer.

Justice

Justice concerns fairness. It applies here mainly to ensuring that Mr. R. receives the same respect and palliative support as any other patient. Justice would be violated if his request were ignored because of his age, his disability or the family's objection. It would also be violated if the clinic encouraged withdrawal to free a chair, which must never influence the decision.

The ANA Code of Ethics

The current code (American Nurses Association, 2025) opens with respect for the dignity and worth that each person holds and with the patient's right to decide about his own care. It next says the nurse's first loyalty is to the patient, while recognizing that families are part of the care context. A later provision charges the nurse with speaking up for the patient and guarding his rights, health and safety. Taken as a set, the provisions mean that the nurse must not keep Mr. R.'s request from the physician, even at his daughter's urging, because doing so would place the daughter's wishes above the patient's right to be heard. The code also supports the nurse's role in compassionate care at the end of life, which includes helping patients and families through decisions to forgo treatment.

Recommended Nursing Actions

First, the nurse should acknowledge Mr. R.'s request, ask open questions about his reasons, and document his words. Second, the nurse should inform the nephrologist the same day, explaining to the daughter respectfully why this cannot be kept private. Third, the nurse should request a capacity assessment and screening for depression, with treatment offered if indicated, without allowing the screening to become a way to delay or override his choice. Fourth, the nurse should ask the social worker to arrange a family meeting where Mr. R., his daughter, the nephrologist and the nurse can discuss goals, prognosis and options, including a time-limited trial of reduced treatment or a referral to hospice. Fifth, if Mr. R. decides to stop, the nurse should help coordinate a transition to hospice so that symptoms are managed and his wish to be at home is met.

Conclusion

Mr. R.'s request tests the nurse's commitment to autonomy against a family's grief and a clinic's instinct to keep treating. When capacity is present and the choice is informed, respect for autonomy and the ANA Code support honoring his decision. The nurse's role is to ensure he is heard, his capacity is fairly assessed, his family is supported, and his remaining time matches the values he has stated.

References

American Nurses Association. (2025). Code of ethics for nurses. https://codeofethics.ana.org/

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Galla, J. H. (2000). Clinical practice guideline on shared decision-making in the appropriate initiation of and withdrawal from dialysis. Journal of the American Society of Nephrology, 11(7), 1340-1342. https://doi.org/10.1681/ASN.V1171340