Drawing Lines

Where should we draw the line on using medical technology to sustain life?

Envision a scenario:

"Wall Drawing #65" by Sol LeWitt

Milt is 87. Over the years he’s developed diabetes, high blood pressure, arthritis, lumbago (back pain), hearing loss, too many moles to count, and high cholesterol.  He sees his doctor three times a year for checkups on these conditions and to keep his long list of medicines stockpiled. He also sees a specialist or two.

Recently Milt developed “a touch” of pneumonia and was hospitalized for three days. Since being there, his doctor informed him that his kidneys “aren’t filtering as well as they used to.” The doc tells Milt that his kidneys are functioning at about 50% of what they were as a younger man, but not to worry since we know that people do just fine with one kidney.

As often occurs with chronically ill elders, Milt winds up back in the hospital six weeks later with “congestive heart failure.” His heart is not pumping blood effectively, so fluid is backing up in the lungs causing shortness of breath. His legs are swollen. The hospital doctors treat Milt with diuretics to “get the extra fluid off,” but in doing so his kidneys now worsen.

Nephrology is consulted.

Based on Milt’s lab data and urine output over the last 48 hours, the consultant tells the docs that Milt’s effective kidney function is zero. The consultant says the only option is dialysis. Without it, Milt will die due to kidney failure.

Fortunately, since 1972, anyone with End Stage Renal Disease in the U.S is entitled to coverage for such treatment.

When the law passed, it was largely in response to the unfairness perceived in who was selected for dialysis treatment when it first became mainstream. When a resource is scarce, someone is inevitably going to be left out.

Fast forward about forty years, and see this really interesting article from my favorite medical journal, the NY Times.

I vant to suck (and filter) your blood.

Dialysis, the article notes, was originally intended for people in whom substituted kidney function would permit them to return to productive lives. As we continue living longer, more and more patients fall into the category of becoming “eligible” for dialysis treatment. As with many medical decisions, deciding whether to undertake it is not as easy as it seems:

Dialysis is difficult, especially for the old and sick. Most of the nation’s 400,000 dialysis patients spend several hours, three days a week, hooked up to a machine, and additional time traveling back and forth to the clinic.

They have to restrict salt and fluids, and the procedure is so exhausting that some patients rest for the remainder of the day. Although dialysis may alleviate symptoms like fluid accumulation in the legs or lungs, it can lead to dizziness, weakness, leg cramps, nausea and other problems. Complications like bloodstream infections or clogged blood vessels where the dialysis needles are placed are common, often requiring surgery or hospital stays. Ultimately, about one patient in five is unwilling to go on with it.

Having treated patients of advanced age with many co-morbidities, I can say first hand that there are some patients I wish had chosen against dialysis. (Here is the courageous story of one.) Not because I’m stingy or want to be on a “death panel.” But because I want them to live out their days with dignity and in comfort, not tethered to medical appliances and suffering for long stretches.

The thorny ethical question is “when should dialysis not be offered?” In the U.S, we have yet to successfully address this question in most of the workaday world of medicine.

Where would you draw the line?