What would you say when an ESRD patient tells you “I don’t want dialysis anymore”. As a registered nurse, you realize what the future holds for the patient on dialysis. It is a tough call; when the main reason is due largely to financial constraints. This is an ethical dilemma that the Filipinos nurses shared with me.
The out-of-pocket cost for dialysis treatment in the Philippines is between 3,500 to 4,500 Pesos for one session; not including the cost of daily vitamins, medications, and renal diet. The recommendation for dialysis is usually three times a week, depending on the level of adherence with prescribed regimen. Many Filipino patients skip dialysis sessions and often showed up at the hospitals when they were not feeling well. I ponder how dialysis patients are able to hold down jobs given that each session takes about 3 to 4 hours every other day and most patients often feel extremely tired afterward.
Family ties are extremely important to the Filipinos. Customarily, family members facilitate the dialogue and healthcare decision-making is shared among family members. I was taken by surprise to learn that patients share their thoughts and feelings directly with nurses. The underlying thought of giving up life-saving dialysis treatment due to financial concerns may be for some but may not be for all. Some patients are receiving free dialysis funded by government or affordable cost from private sectors. It is necessary to assess for depression or other issues such as personal dilemmas of meaning of life, quality of life or feeling of being a burden on family. Or maybe the patient truly needed help with how to tell their family about their decision.
I also learn that it is uncommon for Filipinos to question their physicians’ decisions about their healthcare treatment. Some Filipino patients may feel hesitant to talk with their physicians about the decision to withdraw dialysis, then stop showing up at the clinic. At this point how would the patients and family fully understand the effect of their choices what to expect for end-of-life care. Once dialysis stops, death can occur with a few days and could extend a few weeks because of toxins build up in the blood. In most cases the patient’s physical appearance change: swelling in your face, hands, ankles and feet. Because of fluid back up in the lungs, changes in breathing patterns experiencing shortness of breath and congestion that can be heard like a gurgling sound. This sound can be distressing for family to hear even though it is a normal body process. As toxin accumulated in the body as well as central nervous system; it is very common that patient will sleep more; most of the day; increase restlessness, agitated, disoriented, confusion, unresponsive, and oftentimes the patient does not recognize family members. It is difficult to watch someone you love go through the dying process.
During this crucial time, families need help on how to provide palliative care in order to reduce pain and manage symptoms for their loved-one. Empowering the family also helps ease their fears and anxiety that the loved-one is as comfortable as possible and have peaceful death in their home.
