Unless you have a cynical mind, (or have been trained to question authority) you might agree with this article in the AMA News:

Aggressive end-of-life care for Medicare dialysis patients is pervasive
Hospitalization, ICU admissions and feeding tubes are common. Nephrology guidelines call for advance planning and advise caution in elderly dialysis.

The article goes on to lament that old folks on dialysis get too much medical care, even though “surveys” show few of them (they quote 15% of those 75 or older)  live five years on the dialysis machine.

The problem? they morph these “older” patients with those who are younger (say only a chipper 60 years) but have their dialysis covered by Medicare. Then they ignore the problem of “comorbidity” (other things wrong about you).

Many of these people are diabetics, so end up dying of heart attacks, infections or strokes, not their kidney problems. Remember this when I get to the study below.

Of course, there are arguments not to start dialysis on someone with a long history of Diabetes that has already resulted in a leg amputation, diabetic caused blindness, and a bad heart.

Often dialysis in this case is only prolonging the dying process.

Yet for some, it means not living longer, but living more comfortably, without the air hunger, cramps, and lassitude/depression of chronic renal failure.

And then there are those who do well: they may have only one leg and  are half blind, but they still enjoy life. I’ve seen patients like this who happily chose to have dialysis and live for years.

So the article is dishonest. Here is one “comparison”:

Nearly 80% of Medicare patients on dialysis were hospitalized in the 30 days before death and spent twice as many days in the hospital as patients dying of cancer, said a research letter published April 23 in Archives of Internal Medicine…

Uh, wait a second. This is comparing “apples and oranges”.

How many of those cancer patients were “terminal” and sent home to die, or were admitted to the hospital for care, and then died when the treatment was stopped as “futile”?

And how many times have the patients on dialysis recovered because the docs treated them aggressively in the ICU etc.?

This study shows quite a few patients with chronic kidney failure actually didn’t die.

Overall, our observations on mortality are congruent with those of previous studies examining the effect of ESRD in a more general ICU population (5–12). These studies reported crude ICU mortality rates for ESRD ranging from 14% to 52.6%, bracketing our estimate of 22%. Three of these studies (5,9,15) also performed adjustment for case mix and illness severity and reported a similarly large attenuation of the association between ESRD status and death after adjustment, with adjusted ORs ranging between 0.9 and 1.25. These values lie within the confidence limits of the estimates in the study presented here (Table 3).

Translation: three out of four of them lived.

True, they might die of the infection/heart attack despite ICU treatment, but unlike the cancer patients, they were treated, and therefore they had a better chance to recover: because they were not terminal (emphasis mine).

Often the dialysis patient who has pneumonia will be placed on a breathing machine because they have a chance to recover from the pneumonia with the treatment. Ditto for CPR: Often their heart might become irregular due to a treatable electrolyte imbalance, so CPR is warranted.

Yet the American Medical News report just ignores that treatment might let these people live:

“It’s really a shame that these elderly patients go through such intensive, aggressive treatment, and I’m sure they suffered more because of that rather than being comfortable and dying at home,” said Alvin H. Moss, MD, a Morgantown, W.Va., nephrologist and palliative medicine physician who did not participate in the study.

Wait a second:you give folks a choice, treatment and suffering but dying anyway, or dying comfortably.

What about those 75% who would live thanks to the treatment? Nope. No mention of them here.

Dr. Moss is pushing hospice use for these patients.

“. ..The hospice use for cancer patients is above the national average, and people are more accepting of the fact that cancer patients might be referred to hospice. What most people don’t realize is that most dialysis patients are sicker than cancer patients.”

Fine. But you know, if you dialyzes them, they aren’t sicker at all.

Indeed, they aren’t “terminal”. True, they often die of other diseases, but if you do it right, they don’t die of their kidney failure.

Can one treat many cases of kidney failure “conservatively”? Yes.I’m old enough to remember when we did that all the time.

But the dirty little secret is that it is a miserable way to die. They have to stay on a strict diet, they keep coming into the ER at 4 am not able to breathe because they ate something salty and their lungs filled with fluid, and they were often depressed and wanted to die because they feel so lousy.

And you know what? When we started to dialyze them, voila, they felt so good they change their mind about dying and started again to live.

Of course, in many cases, you can still treat a person with moderate renal failure without dialysis, and indeed we do so all the time. It’s not an “all or nothing” disease.

But why is it that I suspect that this has more to do with cost control than with the welfare of the patient?

You see, in Obamacare, you follow “scientific guidelines”.This quote from bioethicist WesleyJSmith in First Things explains what this means:

The Medical Intelligentsia is bound and determined to devolve medicine into a technocracy. A professional practices medicine, providing optimal care to each patient as individuals. A technocrat is a service provider who provides consumers with medical care according to check lists and rules created by bureaucrats and “experts”–and does so in the context of perceived or imposed duties to general society.

Yes, and that itself shows the problem. It’s the “quality of life” issue again.

The dialysis guideline says physicians should conduct advance care planning and not use dialysis for patients with no decision-making capacity. Nephrologists should “consider forgoing dialysis” for patients with end-stage renal disease who are 75 or older and have many serious co-morbidities, significantly impaired functional status or severe chronic malnutrition, the guideline says.

Heh. I thought this was about patient “choice”, but now they say Nephrologists should be making the decision?

Why have “experts” make the decision (or pressure you to make the correct decision)?

It’s like this Time Magazine article lamenting that Blacks in America get too much medical care at the end of life.  Time calls this “unwanted care” but the dirty little secret is that many want this type of care.

They might see stopping care or giving a lot of pain medicine to their family member a way to deliberatly kill the patient.

They might remember the Tuskegee, Guatamala or Red Lake studies where minorities were used as guinea pigs by the medical establishment.

They also might see life as being in the hands of the deity, so would hesitate to second guess him or her by refusing treatment that would prolong their lives.

So when the authors mention that trying to talk you out of dialysis should be part of the six hours of “advice” paid for by Medicare for patients planning to start dialysis, this might not solve the problem.

In the medical profession, you take care of patients. Yes, we know the statistics, but we also know that sometimes patients who should die just live on and on, while those who should live die despite everything we do.

When we interact with a patient, we don’t see the statistics, but people.

And believe me, I won’t have extraordinary care for myself, but I am very very suspicious at the push to explain why we docs need to make people dead, while articles explaining why we should help them to live are few and far between.

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articles cited in the American Medical News Article:

“Treatment Intensity at the End of Life in Older Adults Receiving Long-term Dialysis,” Archives of Internal Medicine, April 23 (archinte.ama-assn.org/cgi/content/extract/172/8/661/)

“Invited Commentary — Can We Begin With the End in Mind? End-of-Life Care Preferences Before Long-term Dialysis,” Archives of Internal Medicine, April 23 (archinte.ama-assn.org/cgi/content/extract/172/8/663)

“American Society of Nephrology: Five Things Physicians and Patients Should Question,” Choosing Wisely (choosingwisely.org/wp-content/uploads/2012/04/5things_12_factsheet_Amer_Soc_Neph.pdf)

“Shared Decision Making in the Appropriate Initiation of and Withdrawal from Dialysis, 2nd edition,” Renal Physicians Assn., October 2010 (www.renalmd.org/catalogue-item.aspx?id=682)

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Nancy Reyes is a retired physician living in the rural Philippines. She has worked most of her life with minority patients who didn’t trust the medical establishment, and has seen many incidents to confirm why the patients might be right.

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