still fighting old habits

old handsThe very old woman and her almost old daughter returned to clinic. I knew the very old woman had recently been in the hospital twice over the course of a week. She was feeling very weak and sick to her stomach. She could no longer walk. Her anemia was much, much worse. Her hemoglobin level, the blood test for anemia, had fallen from 10 to 6. For 10 we just watch. For 6 we offer a blood transfusion. One needs a hormone produced by the kidneys to make blood. Hard to make blood when the kidneys only function at about 4%, like the very old woman’s kidneys.

Since she was 88, the very old woman said she wanted no dialysis. But now she was 90 and ill and maybe even dying of something that had a treatment. The family wanted dialysis.

Though at least 6 providers had seen the very old woman and her daughter in our clinic for patients with advanced chronic kidney disease over the last 6 months, the hospital team in charge of her care contacted me. Could I attend a family meeting that day to discuss the goals of her care, they asked.

I could not, but I could give them information:

For patients over age 75 with illnesses other than end-stage kidney disease, it has been shown that how long a person lives with dialysis is no different than without dialysis. Further, dialysis worsens quality of life for these patients compared to just managing symptoms without dialysis. This patient would certainly have significant functional decline (mental and physical) with dialysis.

All that said, if the patient and her family change their minds (which people often do out of fear), dialysis can be started. Many nephrologists would have no problem with it. Some would probably even refer her to have a fistula created.

My feeling is that the best outcome/death would be achieved for this patient by not starting dialysis, by checking no more labs, and by involving home hospice in her care.

The hospital doctors thanked me for my input and used it for the family meeting. The very old woman was discharged to home with hospice after being given a blood transfusion to help her feel better. But family remained unsure if this was best, even though their mother remained resolute.

Now a month later, I sat in front of the very old woman and her almost old daughter again. The very old woman in a wheelchair. She looked tired. Her eyes didn’t twinkle any more. She didn't smile. The daughter on the edge of her chair, asking the results of the recent blood tests. They had been to the clinic 3 times since the hospital discharge, twice for a shot of the man-made version of the hormone that the very old woman’s kidneys could no longer make and once just to see the doctor.

Daughter understood that dialysis would not be started for her mother, but she still wanted it.

Why, I asked. Because it would remove the toxins so she will feel better and live longer, she believed.

Daughter had cancelled the home hospice.

Why, I asked. There is nothing we are doing for you here that can’t be done for her at home.

Because my mother is feeling better now. And they said I should call them before I call an ambulance. I don’t mind bringing her here, she said.

The very old woman, not understanding much English, sat silently. No one asked what she wanted.