Saturday, November 19, 2011

Dialyzing our elderly

One of our older patients at NephroPlus passed away last night. He would come in twice a week. His son mostly accompanied him. I have rarely seen a son so dutiful and loving. He would bring in his laptop and work from the couch we provide next to the dialysis bed. The patient was getting tired of the disease. A couple of weeks back he had stopped coming. I talked to this son and wife a couple of days back. They said he was not willing to come for dialysis. They were trying hard to convince him but he just wouldn't listen. I talked to them yesterday morning and was planning to go over to their house this morning to try and convince him to come for dialysis. Suddenly last evening he became unconscious and was rushed to a hospital. But I guess it was probably all over.

Dialysis can be mentally draining. Week after week, without any relief, without any end to the suffering in sight, you go on and on. There is no light at the end of the tunnel for many. The lucky few who get a transplant get some respite at the end of it all but for the vast majority, this is a permanent thing, something they have to endure for life.

This has led many to question the necessity of dialyzing people who have 'lived their life'. Dialysis is not going to cure anything. Neither is it going to make their lives more pleasant. Dietary and fluid restrictions can be torturous. But this leads us to the question, "What if you don't intervene? What if you don't dialyze them?"

Dr. John Agar, an Australian nephrologist of international repute, in an answer to a question on a forum, says, "Conservative (non-interventional) care is a real and often advisable course. By intervention here, I mean machine and equipment intervention. Good studies - really sensibly and well done - have come from the UK and elsewhere, showing that CKD patients >80 years of age with more than one comorbidity ... do as well - or better - and certainly maintain an better quality of life if treated conservatively without dialysis. Their survival is a little less than 3 months shorter (on the average) than matched patients who chose dialysis ... but their quality of life, their hospitalisation rates, their last remaining time, is better."

He goes on to add, "The dialysis only adds to the misery, rather then relieving it."

The key here is whether to start dialysis or not? Once you start it is very difficult to withdraw. So, relatives of patients above eighty years of age must weigh the pros and cons carefully before deciding to start dialysis. More importantly, doctors must think hard about the benefits and the difficulties and then together with the family make this decision. I am not, for a moment, suggesting that we should not dialyze anyone over 80. All I am saying is it is not the same as dialyzing someone who is much younger. I am saying weigh the pros and the cons, arrive at a decision after a logical consideration of the facts and if the decision is that the patient is going to benefit with dialysis, then go for it.

Don't do it just because you have to do it.

3 comments:

Thrinath Chakravarthy Jalamadugu said...

Kamal! For me, it looks something closer to 'Mercy Killing'

Kamal D Shah said...

Is that good or bad according to you?

Thrinath Chakravarthy Jalamadugu said...

If u ask me, Mercy Killing is suggestible to the genuine cases. Its better than seeing your loved ones suffer and you suffer inturn for no relief in the future.