Breaking bad news

One of my patients came in to the hospital for gastritis but ended up staying for a couple weeks because we discovered that she had acute worsening of chronic kidney disease secondary to diabetes and hypertension. Dahlia didn't seem to understand that out-of-control diabetes and hypertension directly caused her kidney injury. Up until this point, she had been asymptomatic. When sick people don't feel sick, and they lack education to understand the illness and money to buy medications, they tend to not take care of themselves properly.

"I know that you came here for your stomach problems, but the reason you're still here is because we found out that your kidneys aren't working well. We think you've been feeling nauseous because of your kidneys, not because of your stomach."

"Okay, doctor, what does that mean?"

"It means that we want to keep you here for a few more days to make sure your kidneys start working better and to get your blood pressure and diabetes under better control."

"Oh, okay doctor. Whatever you say I need to do to get better."

After a few more days with steadily climbing creatinine and continued worsening of kidney function, it became clear that Dahlia was going to need dialysis. If she was lucky, we'd be able to place a fistula for scheduled dialysis rather than start dialysis emergently.

Regardless, I took responsibility for talking to Dahlia about her worsening kidney disease and the need for dialysis. I dreaded the conversation. Like a good medical student, I printed out materials and prepared a pretty little speech to teach my patient about chronic kidney disease and dialysis. She only had one question for me when I finished: "Am I going to die?"

This question nearly knocked me to the ground. I wish that I could say that I provided a thoughtful and reassuring answer. But I didn't. Afterward, I went to my intern to see if he had any advice about how to handle this situation. "Ooooh, I can't believe you pulled the I-don't-have-a-crystal-ball line!"

I felt ashamed, even though implicit in his poking fun of me was the admission that once upon a time he too had fallen back on the crystal ball line. I wanted to be a doctor to my patient, not a medical student, an admittedly impractical aspiration given my inexperience in breaking bad news to patients.

This conversation continued over the next couple of days as her creatinine continued to creep upward, my patient languishing in the stench of her hospital-acquired depression. Each night on my way home from the hospital, I asked myself why I couldn't bring myself to tell my patient the truth. It didn't matter: I just had to tell her.

Brenner and Rector's The Kidney, 8th ed. Figure 17-9. Adjusted 5-year survival of U.S. incident dialysis patients by modality and primary diagnosis. (From U.S. Renal Data System: USRDS 2005 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2005, p 131.)

"The graph on the left shows you what your chances are of being alive five years after starting dialysis. You have an 80% chance of being alive at 1 year, a 60% chance of being alive at 2 years, a 40% chance of being alive after 3 years, and a 20% of being alive after 5 years. That means that for every five patients with diabetes starting dialysis, only one will be alive in 5 years. The outlook is a little better for people with kidney disease but who don't have diabetes; that's why we've been so concerned about controlling your blood sugar. Keeping both your blood sugar and blood pressure under control is the best way to keep you healthy and slow the progression of your kidney disease."

Dahlia's eyes drifted downward then darted upward and rightward and leftward then settled on the picture-perfect 9th floor cityscape that seemed to represent escape from this prison of disease and death. Her eyes looked everywhere except at me.

I finally realized that I had been afraid of burdening my patient with the knowledge of how she was going to die, and when, as if I could somehow protect her with a shroud of ignorance. How small and selfish I had been.

I looked out at the cityscape where Dahlia was still gazing with blank eyes.

"I want to go home."