what the family wants

It was December. Mr. S was well into his 80s and had been trying to die all year. A clot in the lung here. A stop of the heart there. But his best effort to date began simply enough with a trip to the bathroom to brush his teeth. A loud thud brought his wife in to find him lying in the bathroom floor. For 30 minutes he lay there seemingly lifeless before the 911 team arrived and started CPR. After a long while and several IV medications and shocks to his heart they were able to revive him to something slightly above lifeless. His heart stopped again in the ER and once more in the ICU, requiring more IV medications and more shocks to revive him each time. There was a ventilator to make him breathe and several constantly dripping IV medications to make his heart beat better and keep his blood pressure up. The cardiology ICU doctors in charge of his care also cooled his body down to 92 degrees Fahrenheit for a day in hopes of salvaging as much of a brain that didn’t get much blood pumped to it for the better part of an hour one can possibly hope for. But they worried that the inevitable release of potassium into his bloodstream as they warmed him back up to a normal 98.6 degrees would be too much for his kidneys to handle. And very high levels of potassium alone could stop his heart from beating. Again.

I was the attending nephrologist supervising the hospital renal consult service. Our team’s role was to help the primary doctors with any kidney problems they felt needed our expertise. We could look at urine and do biopsies to figure out why the kidneys were failing. We could order dialysis to replace kidneys that had already failed temporarily or irreversibly.

This primary team of doctors wanted dialysis.

Never mind Mr. S’s kidneys had not failed, that his kidneys were still peeing, and that his blood potassium was still normal. Never mind there were medications that could be tried before dialysis. They wanted to go straight to dialysis. Do not pass go. Do not collect $200.

And never mind Mr. S had been trying to die all year and this was his best attempt yet.

We often find ourselves in grim situations very similar to this. Usually the renal team orders dialysis. Sometimes the attending nephrologist agrees: If kidney failure, then dialysis. Always and without question. But perhaps more often than not, the renal team orders dialysis out of surrender. It’s easier to start dialysis than fight with the primary team.

I was prepared to fight.

My like-minded renal fellow explained our position to the cardiology fellow. Dialysis was inappropriate and here are things you can try if the potassium becomes a problem. The cardiology fellow was outraged.

“But this is what the family wants, so this is what we should do!” he reacted as if the family’s love, hope, and guilt trumped clinical reasoning.

Two hours later, my fellow called me. She was exhausted after having argued back and forth with the cardiology fellow. This had become an attending-to-attending matter.

I was nervous about calling the cardiology attending. She was a formidable woman packed into a frame that barely cleared five feet and she had been in clinical practice since I was in middle school.

“I wanted to discuss Mr. S with you,” I said, trying to keep my voice steady.

“Ah yes,” she groaned.

Given my fellow’s interactions with her fellow, I was surprised to find we were in agreement. She agreed Mr. S was already gone and she had no intention of escalating his cardiac care. There would be no adding a pacemaker to keep his heart beating or a defibrillator to try to shock it back into a reasonable rhythmic beating. She agreed that dialysis was futile.

“But the family wants everything,” she added in resignation.

I inhaled sharply, really surprised now given our conversation up to that point.

“The family wants him to get up and walk out of here,” I said. “Nothing we do can make that happen.”


Mr. S’s kidneys did deteriorate. He even stopped peeing for some time and his potassium did rise to moderately high levels, but both were managed without dialysis. But more importantly, after five days there still were no signs of Mr. S’s brain recovering. The cardiology team talked with the family again, explained the situation and recommended taking him off the ventilator.

And the family agreed.