**6. Withdrawal from dialysis**

It is known that the leading cause of death in dialysis is associated with cardiovascular disease and infection. Psychosocial factors are also concerning factors that contribute to death in dialysis patients. Withdrawal from dialysis results in death due to the clinical manifestations of uremia caused by treatment discontinuation. In dialysis patients, withdrawal is categorized as the third-most frequent reason for mortality [110]. In Western countries, the incidence of withdrawal from dialysis prior to death ranges from 20–30% [8, 111–113]. In North America, the incidence of withdrawal from dialysis accounts for 30% of deaths before death [114]. The decision to discontinue dialysis is associated with several factors, such as older age, female gender, white race, and clinical complications [115–118]. A retrospective cohort study of 133,162 hemodialysis incidents found that 10% of patients who withdrew from dialysis were 80 years of age or older [117]. The psychosocial risk factors that could be associated with increased odds of withdrawal from dialysis are depression, low socioeconomic status, and dementia [39, 110, 117, 119]. Furthermore, the most common reasons for considering dialysis withdrawal in many cases are a lack of enjoyment in life, a sense of being a burden on others, a shift in roles, a loss of control, and lack of social support [114]. Also, studies suggest that high symptom burden, such as pain, is associated with withdrawal from dialysis [114, 120]. There are several obstacles in the process of withdrawal from dialysis that relate to patient and family preferences, cultural and religious views, ethical and legal issues, and priorities in policymaking [114].
