Demystifying Medicine One Month at a Time

Tag: dialysis

The Carny

Chico* was a patient we cared for in the hospital.

Admitting diagnosis: “acute kidney injury,” medical-speak for kidney failure. He would need dialysis.

From my point of view–an instructor teaching residents and medical students–there were two key questions about Chico:

  1. What caused his kidneys to fail?
  2. Given his kidney failure was “acute,” was there any chance that it’d be reversible? Could Chico’s kidneys heal to the point where he could resume normal life away from dialysis?

The answers came with time. A biopsy of his kidney showed “interstitial nephritis,” damage caused by calcium oxalate crystals in his kidneys. This type of damage was characteristic of poisoning by ethylene glycol (anti-freeze). Had Chico been suicidal?

“No,” came the answer. Chico was a carny, on the road 40 weeks a year. Part of the lifestyle involved him and his buddies kicking back a few when the show closed each night; his best guess is that someone had spiked a few of his drinks along the way. Anti-freeze is a lot cheaper than good hooch, after all.

Chico was already missing one leg below the knee. He had diabetes and didn’t take the best care of it. Given that, it wasn’t a surprise that his kidneys would be more susceptible to injury than average. After a few days in the hospital, it became clear that Chico was going to continue to need dialysis. Usually patients are ambivalent about this–they feel better physically and mentally from having their toxins filtered out, but there’s also a sense of loss as life becomes dependent on a machine treatment three times per week. Usually those affected are grateful for the life extension, which predominates their emotions.

But Chico was tearful. No matter how many times we tried to explain to him that dialysis was his ticket to continue living (absent a kidney transplant), the thought of being tied down to a dialysis chair was incompatible with the lifestyle he led.

As an itinerant worker, he had no place to settle down and begin the sedentary life of a dialysis patient.

On a logical level, his tears made me feel like he wasn’t comprehending how lucky he was to live in an era with such technology and medical treatment available. Emotionally, I understood his existential sadness. He was a bird whose wings had been clipped. His freedom was gone. The carnival was the only life he’d known.

My hope for Chico is that he is able to find a new equilibrium. If he can’t, he’s not long for this life.

___________________________________________________

*names and identifying features changed to protect patient privacy.

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?

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