Though aggressive medical treatment is expected with a critically ill patient, there comes a time when the paths of quality of life and quantity of life intersect and the patient and/or family might make a choice. Patients with end-stage renal disease are faced with a seemingly impossible dilemma as their health deteriorates: try to prolong life with continued treatment or seek end-of-life comfort through hospice. The dilemma is further complicated by the fact that the way hospice is currently set up prevents Medicare from paying for dialysis (a curative treatment) and hospice (non-curative but comfort care) at the same time. This means that patients who are receiving dialysis (treatment for kidney failure) have to stop life-prolonging care in order to receive hospice services known to boost comfort.

Think of Mary Jane, your mother, a 75-year old women with severe chronic lung disease from berylliosis that she acquired from working in a lighting plan in a West Virginia town. She is oxygen dependent as she wears it around the clock every day. She also has recurrent problems with bronchitis and pneumonia. Now she experienced advanced Chronic Kidney Disease (CKD) that lead to a hospitalization about a week ago. Her attending doctor is now recommending against dialysis because he is afraid that between the dialysis and the lung disease her quality of life would be very poor. Mary Jane responded to the doctor that she still had things to live for and that she wanted to give dialysis a try. The following day, she is talking to you and states: “I do not know what I was thinking yesterday. I think that having the ability to stop dialysis, enter hospice and better control the timing of my death can be “a blessing” for me.” I want you to help me make a decision here. I know it is a tough one, but your opinion matters to me more than anything else.

Based on your understanding of end-of-life, palliative care, and hospice care, how would you address the request from your mother? What factors from the case that would influence your decision? How would you justify your answer?

Keep in mind that at the stage of her CKD, once people stop dialysis, most die within a week or so.


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