I admitted a man in his mid-70s who comes in with fluid overload (too much fluid in the body) with a background of a lot of health problems, including diabetes, high blood pressure, high cholesterol, and chronic kidney disease. His kidney disease has been going on for years. Two years ago, the renal team discussed dialysis with him to potentially prolong life and he refused, because to undergo peritoneal dialysis (a type of kidney function replacement therapy) involves surgery and daily dialysing and he didn't want the bother nor the risks associated. This is fine. In the elderly, the benefit of dialysis is actually not that great and we respect patient decisions.
He has fluid overload because the kidneys are now too bad to pee out the excess fluid and so he became overloaded. With some diuretics (water medication), I offload the excess and he's fit for home. During this time, his kidney function deteriorates further and now he's at end-stage renal failure. There's nothing to do as he refused dialysis at a point where it could have made a difference to his lifespan (a point which he has now passed).
I call his wife to tell her he's fit for home and inform her to be aware that end stage renal failure patients have a risk of sudden death, just to be aware and be prepared in the event he suddenly drops dead. I also inform her that, per previous discussion by the renal team, this is partly due to the disease and partly due to the patient's refusal of dialysis.
"So can we start dialysis now?" she asks.
Aside from an initial reaction of 'Uhh, what???', I didn't know how else to react.
There was a time two years ago when this man could have undergone dialysis to potentially prolong his life and delay the onset of end stage renal failure. He didn't want it then.
Now that he's reached the end stage, there is no point in dialysing. Plus, he still doesn't want it. Dialysis is not a magical cure. It's a way to delay the inevitable whilst maintaining some quality of life at the expense of a lot of hard work on the patient and family's side and home space (peritoneal dialysis fluids take up a lot of space). Some people are not suitable for dialysis and should not get dialysis; it's not for everyone and this is something I'll discuss in another chapter.