One of the miracles of modern medicine alongside such remarkable advances as anaesthesia and antibiotics is dialysis. Millions of lives have been prolonged by dialysis and those lives extended have had an incalculable impact on the individuals concerned and their family, friends and society generally. However, as humans, we know that miraculous good may bring its own set of challenges. From a technology that was, at its inception, carefully reserved for younger, fitter non-diabetic patients, dialysis has, at least in developed nations, been available to the entire population. Therein lies the quandary that increasingly faces clinicians in the use of modern technologies, including dialysis: which patients with end-stage kidney disease (ESKD) will benefit from dialysis and who might suffer? What ethical principles guide this decision making? In what circumstances is a conservative or non-dialytic management of ESKD appropriate? What is the role of palliative medicine?
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