Chapter 18- The Three Ladies

Ray Hsu looks at chapter 18.

The Three Ladies

Dr. Grubbs describes three memorable patients whom she met after graduating fellowship and joining the faculty at San Francisco General Hospital. She encountered these “Three Ladies” as an attending nephrologist at the hospital’s pre-dialysis clinic for patients with advanced kidney disease and recalls each patient’s route through advanced CKD to death.

ONE: Ming Lee 

Mrs. Lee: an elderly, Cantonese-speaking woman with advanced CKD along with many medical problems, with whom Dr. Grubbs attempted to have a conversation about the possibility of conservative medical management of CKD rather than renal replacement therapy. Grubbs was insufficiently trained or confident to pursue what she knew to be a better, more patient-centric, conservative approach to CKD care for Ms Lee. A year and a half later, Dr. Grubbs learned that Mrs. Lee was on dialysis at a Chinatown dialysis unit, where the staff and providers spoke Cantonese. A short time after that, she learned that Mrs. Lee had had jumped off the roof of her apartment building.

I imagined how unheard she must have felt, even in Cantonese. How dark her world must have been, with no sign that the sun would shine. Ever. Again.


TWO: Mrs. Durante

Mrs. Durante was a 63 year-old, wheelchair-bound woman with diabetes, heart failure, advanced CKD, and who had had a complicated and tortuous hospitalization three years prior followed by a long nursing home stay. Mrs Durante was adamantly against dialysis treatment and Dr. Grubbs tried to accomadate her wishes but this slipped bit by bit. She decided to do peritoneal dialysis, then she got an infection. Then she decided to do in-center hemodialysis. Mrs Durante began a trajectory of more and more intensive medicalization of her life with the concomitant loss of agency.

She eventually died in the hospital after the code team was unable to resuscitate her, “in a flurry of tubes, compressions, electricity, IV medications—and dialysis.”


THREE: Mrs. Nisnisan

Mrs. Nisnisan: a 90 year-old woman with advanced CKD “slumped in her wheelchair as if she had no bones.” She had flagrantly abnormal metabolic parameters.  Dr. Grubbs and her team treated the patient for her symptoms, and not her numbers.  The patient stopped having lab tests, and had medications taken away that weren’t making her feel better.  She slept more and more each day, and had fewer lucid, talking moments.

She died at home…”Lying in her bed. Surrounded by all her children. Just how she wanted.”

This chapter highlights how difficult it is to counsel patients—particularly frail, highly morbid, and elderly patients—on their options when faced with advancing kidney failure; and how these soul-wrenching decisions can drastically alter the path to, but not the universal destination of, death.