Several readers have asked me how I handled the transition from CKD to ESRD for my patient (The Best is Yet to Come Part II).
Recall that I told the story of a 64-year old patient who I had been managing for the past 5 years. Lately, her eGFR had been around 5 ml/min/1.73m2. She had been doing pretty well, but when I saw her recently she had developed mild uremia and I recommended initiation of dialysis. The patient became frightened and emotional about the prospect of starting dialysis. Several readers wondered what happened to her? How did she do?
An update on the patient: when I saw her in the clinic I spent most of my time reassuring her about the procedure itself and the impact of dialysis on her life. She had heard this at prior visits, but said that she hadn't focused on it -- "just didn't think it was me that you were talking about". In my patient’s case she had been educated and counseled extensively about starting dialysis. She knew what symptoms to expect. She had already visited a dialysis center near to her; there she had met nurses and other patients. Still, when the day came she had an emotional reaction.
Handling the transition from CKD to ESRD isn’t easy even under the best of circumstances. Patients, like all of us, react differently when we are faced with some dreaded news. Preparing patients for the day is exactly what we must do, but the information that we provide is not always absorbed. And, even if it is absorbed, the reaction to it may vary based on the cultural, socioeconomic, and religious background of the patient.
There are resources one could consult about the transition from CKD to ESRD. Both the RPA and the NKF have guidelines that one can google; I liked an AAKP article for patients. Robert Jan Kossmann in the November 2011 issue of Advances in Chronic Kidney Disease (ACKD) discusses the transition from pre-ESRD CKD to ESRD; however, an older article by Hutchinson from 2005 in Palliative Medicine is better at capturing the emotional aspects.
I can’t be certain that my patient who became emotional about dialysis was influenced by what she had read - the story about dialysis published in Parade probably didn't help. Dialysis is a tough, difficult, and at times painful experience, but it remains a life-saving procedure.