if he was my father

Mr. Navarro is 79 years old and shakes my hand with his left because rheumatoid arthritis has twisted the right like a pretzel. But even with the left, the shake is not the firm palm-to-palm fingers wrapped around my hand kind of shake. It is a more of a dainty how-do-you-do kind of shake that the Southern belles of Gone With the Wind might offer.rheumatoid arthritis His fingers lay limply in my hand. His rheumatoid arthritis is classified as severe and erosive and affects most of his joints. They swell and they ache. All of the time. Recently, Mr. Navarro went to the ER because he had been feeling weak and tired and had lost his appetite. He had lost a couple of pounds and was now just over 100 pounds. He often felt a little better as the day wore on, as people with rheumatoid arthritis tend to do, but because his kidney function had worsened from 24% the month before to 20%, it was wondered if the kidneys were to blame for this 100-pound 79-year-old man with severe, erosive rheumatoid arthritis feeling tired. Maybe he needed dialysis soon, it was thought.

So Mr. Navarro returned to clinic with his son to find out if dialysis would help. Son knew little about dialysis, but was willing to allow it for his father. He is a good son. His father had provided for him. Now he provided for his father. And if dialysis was what his father needed, then he would make sure that he had it.

Truthfully, as wasted away as Mr. Navarro’s body was, his kidney function was probably less than estimates suggested. But even if it were only 15%, starting dialysis would not be clinically appropriate. Kidney failure can be managed with diet and medications at 15 and 20%. And dialysis really only replaces about 20% of kidney function anyway. Regardless, I wondered if dialysis for Mr. Navarro would ever be the appropriate thing to do, even if the numbers said otherwise.

Research studies tell us, I told the son, that people over age 75 and have serious health problems in addition to kidney failure—like your father—will live just as long without dialysis as they will with it. And dialysis is not easy. Especially for 100-pound 79-year-old men who shake hands with the left because rheumatoid arthritis has twisted the right like a pretzel. Dialysis through the blood in the dialysis center, hemodialysis, I told the son, would be the hardest. There would be the time spent traveling to and from the dialysis center three times each week. There would be the inevitable fatigue after dialysis. And there could often be cramping and feeling faint.

Dialysis at home through the belly, peritoneal dialysis, would be easier on his body, I told the son. But a person with pretzel hands could not do it for himself. Family would have to commit to doing it for him. Someone would have to connect tubing from a hanging bag of clear dialysis fluid to a catheter that would be surgically inserted into Mr. Navarro’s belly. It would take 20 minutes for the fluid to drain into the space between the abdominal organs and the skin. Then someone would have to disconnect the tubing. After a couple of hours, someone would have to reconnect his catheter to an empty bag on the floor so the dialysis fluid, now yellow like urine, could drain out in about 10 minutes and disconnect again. This entire process, someone would need to do twice, maybe three times every day. All for him to live just as long as he would without it at all because dialysis cannot change the fact that Mr. Navarro is a 100-pound 79-year-old man with end-stage kidney disease and severe, erosive rheumatoid arthritis.

I didn’t tell the son all this detail of what dialysis at home would require because his eyes had already taken on a suspicious squint as if I might be trying to withhold a treatment his father needed. Like I wanted to just let him die.

Instead, I encouraged him to watch our videos about the treatment options for kidney failure, ask questions, and think carefully about his father’s life and what he hopes for it. But, I added, if he was my father, I would not start dialysis. Son blinked then raised his brows as the corners of his mouth turned downward, like he was surprised I would say such a thing.