Chapter 16- Changing times

Hector looks at chapter 16.

Changing times

In this chapter, Dr Grubbs narrates her experience taking care of two patients, one during her fellowship and one during her tenure as faculty. It reminded me of similar cases I’ve encountered during my fellowship.

The case during Dr. Grubb’s fellowship involved a gentleman with metastatic cancer and kidney failure requiring dialysis. He was sent to the hospital to be evaluated by Nephrology as he was deemed not to be a candidate for chemotherapy, radiotherapy or surgery. Dr. Grubbs evaluated the patient and although she thought that palliative care/hospice was the best option, her attending disagreed and patient was started on maintenance hemodialysis. I’ve experienced similar situations and it always makes me wonder: what specialty is the one deciding for the care of these terminal patients? The primary care doctor who knows the patient better and has established a more personal relationship with the patient? The Nephrologist or Hematologist/Oncologist who are consulting on the patient and think further treatment might be futile, however, they feel uncomfortable taking the lead on hospice or palliative care because they don’t know the patient well enough? Or is it up to the Hospitalist taking care of the patient while they are in the hospital. Of course the hospitalist is afraid to make a decision because she is not the primary care physician. In the chapter, while not described, I think shared-decision making would have been an important aspect that could’ve been discussed. It’s important to give patients and their family members the tools and time to think about the goals of care. I find these type of conversations very difficult. This is an area where physicians need better training so they are familiar with the resources available that can help them approach these situations.

In the second case Dr. Grubbs describes a young, non-adherent, hemodialysis patient. I had a similar case during my fellowship of a young diabetic gentleman with end-stage renal disease, who was nonadherent to hemodialysis. I was assigned to his dialysis shift and after learning more about him, I did my best to find the root of his non adherence. He used to show up in the middle of the night to the emergency department after several days (sometimes 1-2 weeks) without hemodialysis. He was well known to all ER, nursing staff and house staff. I spent countless hours talking to him about hemodialysis, I was empathetic, and an advocate. I also reached several members of his family to try to find the problem. I was unsuccessful. I gave up. I completed my fellowship and he was still around. We tried to help him, but we could never reach him.

As the title of this chapter says: “These are changing times”. Currently, there are thousands of patients that have access to hemodialysis, peritoneal dialysis and kidney transplantation, but there is so much room for improvement. We have more dialysis units, we transplant more people, but we also have more cases of chronic kidney disease and high rates of cardiovascular death. Hospice and palliative care is being offered to our patients.  We need to implement strategies to delay chronic kidney disease, improve diabetes outcomes, provide good blood pressure control and increase the donor pool for solid-organ transplantation. These are the changing times. Changing times could also represent the new healthcare bill with millions of people becoming uninsured in the coming years. And finally, in these changing times, and as health care providers we need to… ”be the change we wish to see in the world…”