Posted on 03.2.2023 | 12:00 AM
as shared by Dr Grace Lee
Dr Grace Lee is a practicing nephrologist with more than 25 years of experience. She is also a member of the Medical Advisory Board in the Kidney Dialysis Foundation (KDF).
I first saw Chew when he walked into my clinic two years ago. He had long-standing high blood pressure and was not regular with his medication. Chew, 58, ran a small construction firm and often worked alongside his workers. Lately, he had a worsening appetite and constantly felt breathless. His wife finally brought him to their family doctor, who diagnosed him with advanced kidney failure.
“How can I have kidney failure? I have no backache or swollen feet. Please check for me again, doctor?” Chew pleaded. He was large and healthy-looking, extremely tanned from working outdoors. But the sallow tinge of his skin and fishy odour on his breath hinted otherwise.
It did not take long to confirm the results. His blood tests were positive for end-stage kidney failure. Increasing symptoms of nausea and extreme fatigue finally convinced Chew to start on peritoneal dialysis.
He was a model patient, diligently learning the process and strictly adhering to nutritional restrictions. His vital readings were neatly penned in his record book, reflecting the way he kept his accounts at work. However, there was one problem - Chew refused to stop smoking.
“This is my only pleasure left. Dr Lee, please don’t take that away from me.” Despite my advice, he went through packs like clockwork. Things took a grim turn a year later.
Chew limped into my clinic one day and complained of severe pain in his toes. When he removed his shoes, many of his toes had a dusky blue discoloration. Upper portions of his right foot were also gangrenous. The pain in his feet was so severe, just a soft breeze blowing by his feet would be excruciating for him. Chew was immediately admitted for antibiotic therapy and required morphine for relief.
An examination of his legs showed that several of his arteries were blocked, causing limited blood flow to his feet. His smoking habit was likely the reason for the extensive blockage, and surgery was not an option. The only solution to his problem was what he feared most – an amputation of the leg. “Is there anything you can do to save my leg?”, he begged.
We knew we had to focus on the solution. Chew agreed to a below-knee amputation of the right leg. A month later, he lost his left leg too. But he was surprisingly upbeat when he returned for his follow-up review.
“Dr Lee, I have stopped smoking! I can even push myself around in my new wheelchair!”, he exclaimed as he performed a few tight spins in my small consultation room while his wife smiled behind him. This was a remarkably resilient couple.
“I’m glad you’ve finally come to your senses,” I chortled. “Of course,” he replied, “I want to be around to see my grandchildren!”
Six months later, Chew experienced the joy of being a grandfather to his first grandson. Time, however, was a cruel mistress. By his next review, I noticed he was wearing white cotton gloves as his hands felt cold often. He tried to appear nonchalant, but we knew what was happening.
The same problem with his legs previously was now affecting his hands. A quick scan confirmed that blood vessels in both arms were narrowed, limiting blood supply to his hands. Neither bypass surgery nor stenting were options. He was started on medication that would help “open up the blood vessels”. We were prepared for the worst.
Chew’s symptoms developed at a frightening speed – the tips of his fingers quickly turned gangrenous in the next few months. It was difficult to watch this stocky man be reduced to tears by the unbearable pain. With a heavy heart, I offered him the option of amputating his arms.
With his family by his side, he said, “Dr Lee, thank you for your care all this time. I will not lose my hands.”
“These hands have provided for my family all these years. They have made me who I am. Without them, I will be useless. Life will have no meaning.” I tried to interject, but he continued. “I have been thinking. You once told me that if I will not live if I did not undergo dialysis.”
“I know my time has come. I want to go with dignity. Dr Lee, can you help me?”
At that point, beyond healthcare and medicine, I had no ready answers. As doctors, we are so focused on saving lives that we forget to listen to our patients’ intentions. We persuade them to undergo treatments or procedures that they may not want. We think we have failed if we did not exhaust all options.
However, I realised that merely extending their lives will not ease their pain. Kidney patients like Chew want comfort with their family in the present. With his simple request for help, Chew understood something which I had stubbornly refused to accept as his doctor - that further treatment will not improve his quality of life. By requesting to withdraw from dialysis, he was courageously choosing to spend his remaining time with dignity.
“Yes, Mr Chew. I will help you.”
Chew was terminally discharged and placed on palliative care. Five days later, with his family by his side holding his weathered hands, he breathed his last. Chew looked serene, like he was finally taking a well-deserved rest after a hard day’s work.
 Peritoneal dialysis is a form of self-administered dialysis done at home through a catheter in the abdomen.