Self-Directed Death by ESRD Patients: Suicide vs. Voluntary Termination of Hemodialysis


  • Tony Salvatore Montgomery County Emergency Service


In the late 1980s, I worked for a large company, which, at the time, operated most of the hemodialysis centers in the United States. My job was with a division that supplied a nutritional therapy to patients during their dialysis sessions. My intro-duction to the topics discussed in this article occurred during a visit to a dialysis facility in Southern New England in 1989.

I was to meet with some of the clinical staff. When I arrived that morning, several staff members were huddled outside the building. When I entered, the receptionist was wiping away tears. She told me that a patient had died and everyone was upset. She would check on the status of my meeting.

I took a seat in the lobby. Sitting across from me was an older woman. She must have noted my suit and briefcase and asked if I worked for the company. I said yes and she told me she was a new patient. She went on to share that she did not have kidney disease, but her kidneys were severely damaged by a medication that she had taken for a cardiac condition.

She was glad that her meeting was delayed because it gave her more time to think about the decision that she was facing. She was ambivalent about starting hemodialysis, but her family had urged her to discuss her situation with the medical director and social worker at the center. She said, “I’m sure that they give good care here, but after all that I’ve been through, I don’t know if I want to do this for the rest of my life.”

At that point, the nutritionist came and took me to a conference room. She told me that a long-term patient had taken his life at home the night before. She and her colleagues were struggling to come to terms with his death. I offered to reschedule but they wanted to go ahead to get their minds off the situation.

About a week later, I had a conference call with some of the center’s staff. At the close of the call, I asked the social worker about the woman I met on my visit. Of course, she could not discuss a particular patient; however, she did say she had worked with several patients who elected to stop dialysis, as well as a few who opted not to begin it. She said the issue frequently came up at regional meetings of dialysis center social workers.
I asked the medical director of the dialysis division about the incidence of suicides among patients. He told me that they were not common but most centers had the experience. About 10 years later, I began my present post, which involves crisis intervention and suicide prevention. Every morning I pass a dialysis center on my way in and I often think about the patients and staff, and what I learned at that other dialysis center so many years ago.

Author Biography

Tony Salvatore, Montgomery County Emergency Service

Tony Salvatore ( is the director of Suicide Prevention at Montgomery County Emergency Service (MCES), a nonprofit psychiatric emergency service provider in Norristown, Pennsylvania. He is the founder and a long-term member of the Montgomery County Suicide Prevention Task Force. Salvatore is an active participant in suicide prevention efforts at county and state levels. He has authored many articles on suicide prevention in adult and older adult populations. The American Foundation for Suicide Prevention recognized him for contributions to regional suicide prevention and postvention.


Personal Correspondence, Network 4: Quality Insights Renal Network 4, King of Prussia, PA. September 24, 2019.

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ESRD Patients, hemodialysis chairs lined up.



How to Cite

Salvatore, T. (2020). Self-Directed Death by ESRD Patients: Suicide vs. Voluntary Termination of Hemodialysis. Patient Safety, 2(1), 10–14. Retrieved from
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