The Women Who Did Not Mean â€œNOâ€
A case history *
An 82 year old Italian speaking grandmother with a very dedicated and loving large family was coming to the hospital three times a week to receive hemodialysis for kidney failure. This is a four or five hour process where tubes are attached to her blood vessels through a special connection called a fistula and her blood is run through a machine with a filter system to clean it of toxins since her kidneys are not functioning properly. She was viewed as having been depressed for approximately two years and frequently would be reluctant to come for her dialysis. She was on Prozac, an antidepressant, for about one year with no apparent change.
Most recently the patientâ€™s fistula clotted and there were no more readily available sites to reconnect the equipment. Surgery was recommended to create a new vascular site for the dialysis but the patient refused to go along with this procedure. The family explained that she had suffered enoughÂ and now just wanted to stop the dialysis and peacefully pass away.
The first psychiatrist who saw the patient interviewed her with the family as translator and also understood enough Italian to confirm that this was what the patient was requesting. There was no evidence of significant depression or overt psychosis. The family was very sad about this decision but felt strongly about respecting her wishes.
Because of the finality of such a decision, it was not unusual to have a second psychiatrist see the patient and I was asked to see her. Rather than use the family as a translator or have them be present during the interview, I asked a nursing supervisor who spoke Italian to do this task.
The patient related well and showed a clear sensorium, very much aware of her surroundings and the situation. She said that she did not want to die and enjoyed being at home visiting with her grandchildren and watching television. She was not in significant discomfort. However she believed that her children believed it was time for her to move on. She wrongly thought that her medical care was a financial burden to her family. She also believed that family members who brought her for dialysis were taking valuable time away from their jobs and family. She even could give examples of things that they had said to confirm this. She believed that the proposed surgery to establish her dialysis site was very unusual and the doctors resented doing it . (Both of these ideas were not true).
Therefore she thought that the right thing to do was to refuse the procedure and peacefully die. She viewed her family as respecting her statement that she did not want dialysis as proofÂ that she was a burden to them.
I needed to do some sensitive delicate follow-up work with the patient and her family to get the patient to accept the surgical procedure and continue on dialysis. Once the family understood that the patient enjoyed her life and was not ready to die , they become very supportive and determined to help her in every way that they could.Â The family arranged a rotating schedule of drivers for her dialysis that included the grandchildren, which proved to very gratifying for all those concerned.
It should be mentioned that there are patients who decide to go off dialysis and end their lives. Most hospitals have a process usually in conjunction with a Hospital Ethics Committee where this can take place.
*This Case history is based on a case report in aÂ a book that I wrote with Dr. Maria Tiamson-Kassab titled Practical Guidelines in Psychiatry- Psychosomatic Medicine published by Wolters Kluwer/Lippincott Williams & WilkinsÂ 2nd E dition (2009).
In 1972 the US Congress passed legislation providing that Medicare would cover the costs of dialysis regardless of the age of the patient. An important part of the debate concerning this legislation was when an actual patient was put on dialysis in front of the Congressional Committee discussing this impending bill. The statistics on the prolongation ofÂ lives in the United States because of the treatments nowÂ available are quite dramatic. While most of these treatments areÂ done at dialysis centers, there are specific types of dialysis that allow it to be done at home with home dialysis or in an ongoingÂ continuous manner, known as Continuous Ambulatory Peritoneal Dialysis (CAPD) ,Â while a person goes on with their usual activitiesÂ ManyÂ people undergoing this treatmentÂ haveÂ been able to maintain aÂ very good quality of life. However, the time on dialysis has obviously altered peopleâ€™s life styles and so have the medical complications thatÂ can occur with renal disease and the various treatments for it. There are also psychological sequelae of this medical condition and treatment. Advances in renal transplantation have allowed many people to come off dialysis after receiving a kidney transplant from a cadaver or live donor ( often a close relative ) This situation is a major life event and has itâ€™s ownÂ medical and psychological implications. Many psychiatrists and other mental health specialists, particularly psychiatrists who are in the recently certified sub specialty field of Psychosomatic Medicine are interested in these issues. I look forward to discussing this topicÂ in future blogs.
Your comments are welcome.