On average, this group survives less than six months after starting dialysis. It would be an alternative to dialysis, managing patients’ symptoms of progressive kidney failure with the goal of maximizing the quality of their remaining time without dialysis - when the risks of dialysis outweigh its benefits, as it often does for frail, elderly patients over 75. N that I have been working to create a conservative management program as part of the nephrology clinic at Zuckerberg San Francisco General Hospital. Instead, she died two years later - at home, pain-free, and surrounded by family. And she likely would have needed procedures and even hospitalizations to keep doing them. She probably would have experienced lightheadedness or cramping during the treatments. N would have felt very tired after her dialysis treatments. Many of my colleagues would have started her on dialysis, contributing to the fact that patients over 75 are the fastest-growing group starting dialysis, doubling over the last two decades.
N, an 88-year-old woman whose kidneys filtered only one teaspoon of blood each minute when I met her.
People with just a little bit of kidney function usually live much longer than two weeks - often months, sometimes years. One study found that elderly people who had dialysis lived on average a year longer than those who didn’t - but almost all of this added time was spent in the hospital, traveling to and from dialysis, or undergoing dialysis treatments. In fact, it often worsens their quality of life. Several European studies have shown that dialysis does not guarantee a survival benefit for people over age 75 who have medical problems like dementia or ischemic heart disease in addition to end-stage kidney disease. Because they believe dialysis always prolongs life, and prolonging life is all that matters.Įxperience has given me different lessons.ĭialysis may not be the best option for everyone with kidney failure. They never say, “Are you sure you want to start dialysis?” because they believe dialysis is always the appropriate response to kidney failure. They say it over and over again every time the patient comes to the clinic until he agrees - or stops coming back. They tell patients, “Start dialysis, or you’ll be dead in two weeks” or “You have a responsibility to your grandchildren to be here.” They even say, “Just try it, and if you don’t like it you can stop,” without offering a vision for what they hope dialysis can do and by when. She went on to an exasperated, “Why does he keep coming back here if he doesn’t want dialysis?”īecause she was new to nephrology and the care of patients approaching end-stage kidney disease, I shook my head in disappointment, thinking, “They got to her first.” She told me his basic medical history and then said, “So I just told him, ‘If you don’t start dialysis, you’re going to die.'” She tilted her head and nodded in that way we clinicians do when we think we’ve summoned the courage to say what needed to be said.
I was the supervising nephrologist, so I asked her how things were going with the patient. His kidneys were filtering about 4 teaspoons of his blood every minute when normal is 25 teaspoons. She had spent the last hour with a 75-year-old man with severe chronic kidney disease. The nurse practitioner exhaled completely as she plopped down next to me in the clinic workroom - as if she had used up her last bit of energy.
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