Age and dialysis: It's a case-by-case decision

December 21, 2009

Age and dialysis: It's a case-by-case decision

Otherwise healthy 90-year-olds can be good candidates

By Shari Rudavsky
shari.rudavsky@indystar.com

When the doctor mentioned dialysis to Ben Reck, then 94, he dismissed the idea. "At my age?" he said. "That's a waste of time."

And some might say offering such treatment for the elderly is a waste of money.

Reck's story shows there's no easy way to make blanket decisions about health-care treatment based on age just to control costs.

Nine months ago, Reck opted to join a rare cadre of very elderly patients on dialysis, an $80,000-a-year-treatment paid for by taxpayers. Dialysis performs the kidneys' job of cleansing the blood of toxins.

Without it, Reck would be dead in six months, his doctor said.

With it, Reck -- now 95 -- still attends family gatherings, auctions with his son and outings with his girlfriend. His family helped him make up his mind. They weren't ready to lose him.

More families may face such thorny decisions as the Baby Boom generation ages and medical science identifies new, expensive treatments to stave off the end of life, said Daniel Callahan, a 79-year-old bioethicist and president emeritus of the Hastings Center for Bioethics in Westchester, New York.

"The real question is what should we do about the future," said Callahan, who 20 years ago wrote a book called "Setting Limits: Medical Goals in an Aging Society."

Reck's doctor Allon Friedman, who had never placed someone as old as Reck on dialysis, said deciding whether to offer an elderly patient this treatment can be "agonizing." It's not always clear how long dialysis will extend or improve a patient's life.

When Friedman first read Reck's chart on a Sunday morning last March at Methodist Hospital, his heart sank. The patient he was about to meet was 94.

Then he walked into Reck's room. The man lying in the hospital bed was alert and vibrant. His mind was sharp. His heart -- aside from having to handle the fluid dumped on it by his rogue kidneys -- was strong.

Until a few weeks before that, Reck had had few health problems. He took walks, drove and lived in his own apartment.

Dialysis, Friedman realized, might extend Reck's life and, just as important, maintain his quality of life.

"This type of thing needs to be done on a case-by-case basis," said Friedman, an assistant professor of medicine at Indiana University School of Medicine. "In some instances, offering dialysis would have been inappropriate. . . . In this situation, it was appropriate."

Fewer than 400 of the 367,604 people in this country on dialysis are age 95 or older, according to the most recent statistics from the United States Renal Data System, an agency that collects information on end-stage renal disease.

As long as taxpayer-funded Medicare covers the costs, the question of whether the money spent on elderly dialysis patients could be better spent elsewhere is moot, Callahan said. He favors a universal health-care program with a fixed budget.

"So we're stuck with a bad system that invites this treatment, and by virtue of technological advances makes it easier and easier to provide such treatments," Callahan says.

In the U.S., there are few guidelines to help determine when to place an elderly person on dialysis. Great Britain places limits on how much each dialysis center can spend, which can result in seniors being denied dialysis, according to Dr. Leslie Spry, a spokesman for the National Kidney Foundation.

"You will not find a lot of information out there about dialysis and the elderly, because we all take it on a case-by-case basis," Spry said.

He has two 92-year-old patients on dialysis, one of whom walks the two blocks from her apartment to the treatment center.

"My experience in these folks is that I certainly do not increase their longevity, but I might help them stay out of the hospital and feel better," said Spry, a kidney specialist in Lincoln, Neb.

Dialysis doctors may be reluctant to work with the elderly, said Arlene Mullin-Lane, founder of the Web site Dialysis Ethics.

"Usually I would say that they're discouraged at the gate. I commend the physician who did this. I really do," she said.

For the past nine months, Reck has awakened three days a week before 5 a.m. At six, his son arrives at his Northside residence to drive him to the Clarian Health Adult Dialysis Center on the Near Northside, where he spends the next four hours tethered to the dialysis machine.

Around 11 a.m., Reck's companion arrives to take him home. He eats lunch and takes a nap. There have been a few times that the dialysis has left him feeling woozy, but that doesn't last long.

"A half an hour and I'm myself," he said.

Reck was born in McKeesport, Pa., and moved to South Bend shortly thereafter. The child of immigrants from Eastern Europe, Reck recalls soldiers celebrating in the streets at the end of World War I.

At age 9, he drove his first car -- a Model T. On his most recent visit to the Bureau of Motor Vehicles, the clerk asked him to take the eye test. He rattled off the letters and she said, "That's not fair. You memorized it."

Reck still drives.

When Reck was 56, his wife died and he moved to Indianapolis, where he continued to work. At the age of 69, he retired but continued to work for another 11 years, until he had to have a hip replaced.

Other than that operation and a childhood case of asthma, Reck said he has been healthy most of his life.

"I'm the oldest one in my entire family. No one has lived as long as I have," Reck said.

Every other weekend, he enjoys a visit from his 6-year-old great-grandson. He goes faithfully to family parties, birthdays and bar mitzvahs. On Tuesday nights, he and his girlfriend dine out with another couple. He regularly attends the theater.

"I just can't believe I feel this good," said Reck, adding that he sees no reason to stop dialysis.

"As long as he tells me to be on dialysis," he said, pointing to Friedman, "that's as long as I'm going to be on it."

Friedman said his experience with Reck has driven home that the most humane medical system will never place limits on who should or should not receive treatments like dialysis.

"It was a good decision in retrospect," he said. "I wouldn't offer dialysis to every 94- or 95-year-old whom I encounter."

http://www.indystar.com/article/20091221/LIVING01/912210338/1083/LIVING01/Age-and-dialysis-It-s-a-case-by-case-decision