Good vs. bad dialysis candidate?

[capeguy]

Hello all. My 87-year-old dad has lived with me for the last 1.5 years. He's been mostly o.k., but his health has started taking a downturn. His GFR dropped to 28 in March, then 23 in mid June and last week it hit 15. Creatinine is at 3.76. He sees his neph again in three weeks (with more tests the week before). He's also just been diagnosed as Type II diabetic, but not terribly so (a.m. glucose generally between 150 and 180). He doesn't seem to be showing many esrd symptoms yet, beside a big drop in his energy level.

I'm kind of a research hound by nature, so I've been doing a lot of reading online about dialysis. It was a surprise to me to learn all the extra diet/fluid-intake worries that go along with the process. The thing is, I don't think my father will be willing to give up all he'll have to give up. First off, he's refused to cut back on his scotch, though his pcp has pushed him about it repeatedly. He typically has two doubles, on the rocks, every night, along with a possible beer or manhattan at lunch and, sometimes, a nightcap before bed. I've actually measured the amount of liquid (including the ice) in the doubles and it comes out to almost 8 oz. each. So that would be almost half his allowed fluid intake for the day. And then there will be all the dietary restrictions to deal with.

So I have a few questions for you folks... first, what's the general number when the docs start pushing hard for dialysis? And what alcohol restrictions do patients face? I'm very willing to help him with the dietary stuff, but it sounds like this can be just a miserable experience for the patient and at 87, I really question whether the process would be worth giving up the few things he still enjoys to gain, maybe, an extra year. Do you folks know people who have simply said "no", or walked away from dialysis after starting?

I hope these questions/observations aren't disrespectful of all you and your families have been dealing with. It just seems that you would have a really good perspective that could be especially helpful to me right now.

[paul.karen]

There are a few posts here where people generally elderly people have given up on dialysis.  It is sad but can be made so the patient is comfortable.  I cant find the link but look around you will find it im sure.

As for liquid intake does your father still urinate pretty well?  This is a factor.

Also will you be pushing for PD or hemo dialysis this also can make a difference.

Im fairly new to all this myself so im sure people can help you much more then me and my limited knowledge.

But your a Great son from where i sit.  Maybe cut the afternoon drinks but dont take your fathers scotch away IMO.

[capeguy]

Thanks for the note. My one agreement with my sisters when I moved my dad in with me was that I wasn't going to be his booze cop. It's a brick wall that no one has ever been able to bulldoze through, and it will turn me into a raving, foaming-at-the-mouth loony if I try to be the one. And, honestly, in his situation, you'd probably be prying my shaker and martini glass out of my cold dead hands (possibly literally).

I'm open to whatever choice he makes, so long as he makes the decision knowing all the facts around each option. I'm not going to push him in either direction, because I really don't know what choice I'd make in his spot. He already has a very hard time walking because of peripheral arterial disease and he's in the early stages of congestive heart failure. The doc has had to take him off circulation meds because they can cause stroke in CHF patients, so his legs and hips hurt like heck when he walks. He still drives back and forth to the senior center to play poker a couple times a week, but otherwise his life is mostly spent on my living room sofa in front of the tv. And now his back is starting to hurt badly, too.

So, if the option is to go through a whole series of procedures to get a dialysis connection and then get shuffled to a center three times a week and, on top of that, deal with all the dietary stuff and the dr's yelling about the booze, or just sort of fade away - which, at 87, is likely to happen pretty soon, anyway - well, like I said, I see both sides...

[monrein]

It's not an absolute thing as to when one starts D.  Following the failure of my first trx after 23 years I started back on D with a eGFR of 16 because I was feeling truly awful, horrid ammonia breath, no appetite etc etc.  The number that's usually tossed around for starting is 10.
Fluid intake very much depends on residual kidney function and urine output can be still acceptable at first but decline as time goes on.  Some have no fluid restrictions at first but must monitor how this changes.  I personally don't drink alcohol but I think that the issue would most likely be around fluids rather than the alcohol itself but the doctor would be the one to ask about that.  Others here will jump in too I'm sure.  Scotch would be better than beer just because of less fluid.
Diet can be very tricky and the restrictions are many.  I choose to do the medically healthy thing and take the restrictions to heart but I've been dealing with ESRD since I started D at 26 and I don't want to die young or, even more importantly, add to the medical issues that I must already deal with.  At 87, your Dad's situation is somewhat different.
There have been people who refuse D or quit after starting and that is always an option.  It's an important one too because it's helpful to know that this last little bit of control is still available to us.  I've never come close to feeling like I want to do that but I like knowing that the option is there.  Quality of life is important at any age and at 87 I'm not sure I'd be too keen on giving up my little "pleasures" either.  Your Dad certainly has the right to carry on as is and it is not considered suicide to refuse treatment.

I think you are wonderful for helping your Dad the way you do and for respecting his choices even as you research what would be best for him medically. 

[RichardMEL]

You're obviously a caring son for wanting to help your dad as much as possible and reading up on the information - it can't be easy for you to read some of the stuff then try and relate that possible situation for your own father- bravo to you!

Just on the scotch... I'm tempted to say - don't worry about it. He's 87 years old. Let him have some enjoyment out of life. If it comes to dialysis and fluid restrictions (obviously if he decides to go with PD the fluid may not be so much of an issue) come into play - specially if he stops passing a lot of urine - which usually happens once dialysis starts - at least scotch is not a high volume sort of booze (compared with beer or wine).

As a hemo patient I've never been given ANY restrictions alcohol wise, though I believe beer may contain a bit of potassium(or is it phosphates? not sure one of those) but probably not enough to make a real difference. Scotch is probably fine from that point of view - vodka or another clear spirit I believe is the "best" from that point of view. It would be the fluid volume that might become a concern. Yes, if he's having 16-20 oz of alcohol a day that may become an issue for him, but probably only in terms of the fluid volume rather than the alcohol content.

Like I said above - he's 87. It's going to be difficult if he has to go on some form of dialysis (which seems likely given the very rapid decline in the eGFR ). I certainly wouldn't be saying get off the booze.. maybe cut down on it (specially if it could have an affect on his diabetes, or any other conditions). I suppose the best way to tackle that one would be to make it about the fluids rather than about *what* fluids he's taking in (because remember obviously his total fluids in will include waters, juices, ice cream, soup and so on). When this becomes an issue for you both to explore I'd approach it from the fluid volume pioint and suggest if he cuts down on everything it will be much better for him, rather than focusing on the alcohol will probably will make him grumpy and more resentful I reckon.

Hang in there and I hope your father does not have to embark on a dialysis journey anytime soon!

[greco02]

My husband just turned 60 and is headed for either dialysis and/or a transplant, or maybe even no treatment.   I have the same attitude you do capeguy.  I support his decision.  I am not the one living with the pain or the disease.   He likes his booze (even if it is to mask his feelings) but doesn't sound like he drinks as much as your Dad.   I say more power to him at his age.   

I work for a medical clinic and a long time ago I heard a doctor on the phone with a nursing home.   Apparently his patient was on a salt restricted diet and he was refusing to eat because the food was too bland.  The doctors answer, give him the salt for crying out loud,  he is 87 years old and in a nursing home for goodness sakes.  Which would you rather have him do?  Eat or not eat?

Good luck.