Advice for family...

Trauma Columnist · May 26, 2017

I'm very sorry you and your family are going thru this.

I'm a nephrology APRN. Here are some points to consider:

Pts over the age of 85 years have high mortality:

From a 2014 study: Survival of chronic hemodialysis patients over 8

StarBrownRN · May 28, 2017

I feel your family's anguish. My family faced a similar decision when my grandfather was diagnosed with cancer at 81 and already had CHF with frequent episodes of pulmonary edema. We had to ask ourselves was it worth putting him through radiation, chemo and surgery at 81 so that he could live in misery for another year, maybe two.

At 85, with his many co-morbidities, dialysis will most likely not extend or improve your Grandfather's life. Rigors of it may take away from his quality of life in a way that isn't worth it.

When I was in chronic dialysis, we referred to it as dialyzing the dead. I know it sounds harsh, but for some patients the treatment was futile and they were miserable--but their families made them do it.

Guttercat, ASN, RN · Jun 1, 2017

TraumaRUs and StarBrownRN have already given great points to consider.

The question to ask (at your grandfather's stage) is ...what does he want?

It sounds like he is at the tipping point as far as his renal function goes, but to put him on dialysis now might not prolong his life with any quality. Indeed a tough question.

Edit to add: patients with an ejection fraction such as your grandfather's often do not tolerate dialysis well.

Cwalz5 · Jun 1, 2017

Thank you all for responding... I wish my grandfather still had the mental capacity to really tell us what he wants but after these last 2 rounds of hospitalization and now being in rehab his mind hasn't returned to baseline. His kidney doctor pushed my grandmother and my mother and they now feel like if they don't start dialysis they'll be killing him and that they have to do something. Based on your advice and knowing my grandfather I really don't think dialysis is the right thing for him but this doctor is promising miracles about his mental status returning to normal and his activity level increasing and his chronic pleural effusion and heart failure going away and so family has chosen to move forward. He had a chest X-ray for pretesting for permacath placement and they found he has too much fluid on his lungs for him to stay in the rehab and are sending him back to the hospital. It's like a nightmare. I feel like I have become the advocate for death but all I want is for him to be comfortable and at home and to not live whatever time he has left in and out of one medical facility or another.

thank you all again for your advice and for taking the time to answer me.

AlabamaBelle · Jun 2, 2017

The advice given by traumaRUs and StarBrownRN is excellent. Having worked acute dialysis for the last year, I can honestly say that I would not have put any of my family members on dialysis after the age of 80 with all your grandfather's problems. The ejection fraction alone is very concerning and an indicator than dialysis could be problematic for him.

I was running one patient in the same age range whose cardiac function was better, but had other problems. The patient looked at me countless times and mouthed "Please help me, please stop this." The patient's family would not listen and one person had POA. Finally, reason prevailed and dialysis was discontinued. The patient slipped away comfortably on the patient's own terms. I am still haunted by still that fragile arm with 15g needles and running those treatments and tears poured down the face. Even on a reasonably, otherwise healthier individual, dialysis is hard. It is not a be all, end all cure all for fluid in the lungs. Dialysis comes with many risks, which must be considered.

Know that you are advocating for your grandfather's dignity and the right to die without being "done to" and not "being done for." I would personally not choose this for myself and my living will says so, rather emphatically.

Cwalz5 · Jun 3, 2017

Update: I was able to speak to my grandfathers primary doctor for this admission and told him about our dislike of how pushy the nephrologist was being and asked if it was worth talking to a different doctor. He initially said the result would be the same and that my grandfather would need dialysis eventually. When I told him that he was scheduled for permacath placement and for dialysis to start before the end of the month he gave us the name of a different nephrologist and called him to come see him. It is such a difference! He sat down with my grandparents... actually sat in he hospital room... and closed the door so they couldn't be interrupted and spoke with them for an hour... he sees the whole picture and is worried about his quality of life! It's amazing how much a good medical professional can set your mind at ease..

thank you again for your advice! It helped me stick to my gut and push for what is right for my family! It will still be a tough choice when we have to make it but at least now I know we have a doctor who has his best interests in mind... thank you thank you thank you

mallardduckling · Jun 10, 2017

Your account is so touching. My mom began hemodialysis at age 82 but with no comorbidities, untreated HTN is what led to her kidney failure. The first few months were rocky with numerous episodes of super low BP as her dry weight increased due to a better appetite. But then she did spectacularly well for five years until heart failure and aspiration pneumonia could not be overcome. I won't comment on your beloved grandfather except to say I'm so happy you had the 2nd nephrologist's opinion. We were also lucky to find a kind nephrologist, and even though the advice to begin dialysis was wise and accurate, I still remember the compassion with which he delivered the information pro and con. On another note: TODAY I GRADUATED with an ADN in nursing! I am 59 years old! I'm considering dialysis nursing (along with med-surg and mental health geropsych) because of the special experiences my mother and I had with wonderful staff. I wish you the best.

Cwalz5 · Jun 25, 2017

Thank you all again.. just one last update.. my grandfather passed away Tuesday morning... over the last few weeks his dementia got worse.. he started hallucinating and forgetting who we were and really wasn't eating... my family was with him on Father's Day and he had a very good day.. on Monday my grandmother called me crying because the nurse at the rehab had asked about a dnr Sunday night and even though she hadn't agreed to the dnr she had come to terms with him being so sick... then Monday morning we got a call that he had been found unresponsive and they had started cpr.. he was pronounced in the rehab and looked so peaceful... like he had just closed his eyes to rest... my grandmother later said to me, "thank god we didn't do dialysis.. it would have been too much" ..I was so glad she was at peace with it and felt that his last few days were good ones.. thank you all for your support and for helping my grandfather be pain and suffering free as much as he could have been... thank you.

Trauma Columnist · Jun 28, 2017

So sorry for your loss but agree with your decision.