Most guidelines are based on low level evidence, relying on expert opinion or current practice.

Various aspects of the management of ESKD patients on a non-dialysis pathway are covered in guidelines that include: Liverpool Care Pathway St George Hospital web-site North America Mid-Atlantic Renal Coalition (MARC) and Kidney End of Life Coalition CARI Guidelines Canadian Society of Nephrology Renal Physicians mTOR inhibitor Association (RPA) of USA UK Renal Association UK Renal National Service Framework NSW Department of Health – Conflict Resolution in End of Life As a foundation principle, the law neither seeks nor expects perfection from doctors. What it does expect is that doctors, including Nephrologists, act reasonably in all aspects of diagnosis, investigation and management, where reasonableness is assessed by reference to competent peer, professional practice. A doctor incurs no civil or criminal liability if, on the basis of a refusal to commence or continue dialysis, the

doctor does not give that treatment. To go ahead and give treatment to a patient who has refused consent constitutes a battery. Advance directives are recognized at common law in both Australia and New Zealand. There GPCR Compound Library are some variations among jurisdictions in the application of advance care directives; these are tabulated in Section 18 of this document. For competent patients, the law expects that consent must be voluntary and made without undue influence and that consent should be informed. This means that the patient should be told about the material risk of having or not having dialysis. If the actions of a Nephrologist are reasonable in withholding dialysis or withdrawing from dialysis then it is highly unlikely that a successful action in negligence would occur.

The law does not obligate a Nephrologist to provide treatment that they believe is of no benefit to the patient or that any benefit is outweighed Cetuximab research buy by the burdens of the treatment, but best practice requires that the Nephrologist communicate with the substitute decision-makers regarding the patient’s best interests. The withholding of or withdrawing from dialysis is not euthanasia. Equally it does not constitute Physician Assisted Suicide. Jurisdictions have variations on whether and which substitute decision-makers can consent to dialysis being withheld or withdrawn; these are tabulated in Section 18 of this document. Competency requires that the person understands what is being said to them, retains that information, and exercises reason to reach a conclusion.