I work in chronic dialysis and I have had to the "its time to withdraw" talk with several families and patients.
The principles that I use to make these decisions are included in the following:
1. Using the utilitarian approach which covers the greater evil. So...I look at what the worst case scenario is - whether by continuing dialysis, what qualify of life is the patient experiencing.
2. The rights approach:
"The right to the truth: We have a right to be told the truth and to be informed about matters that significantly affect our choices.
The right of privacy: We have the right to do, believe, and say whatever we choose in our personal lives so long as we do not violate the rights of others.
The right not to be injured: We have the right not to be harmed or injured unless we freely and knowingly do something to deserve punishment or we freely and knowingly choose to risk such injuries.
The right to what is agreed: We have a right to what has been promised by those with whom we have freely entered into a contract or agreement".
I ensure that I do what is right for the patient with input from the patient and involved family members.
3. The fairness approach - is it more fair or just to continue dialysis when the quallity of life is so poor as to be nonexistent?
4. The common good - this isn't used as much because it denigrates the pt to being a cost. Life isn't something we can put a monetary value on. However, I look at the cost to the person in terms of being dragged to dialysis in the winter, in the rain, etc. This is especially important when the patient is not able to be a part of the decision making process.
Hope this helps.