Shades FREE

Sometimes, melodrama is necessary. At these times, dialogue sounds like a bad made-for-TV movie, like something you've heard before while watching actors play a role: hackneyed, yes, and cliché-filled, certainly.

From “This isn't a minor problem, sir, this is life or death. Without treatment, you will die.” (Did I really say that?)

Mr. B. was a 62-year-old African American, with a history of hypertension and diabetes. According to the triage note, he presented to the emergency department because his feet hurt, and he thought he was having an attack of gout. We physicians are sometimes an unsuspecting lot. We pick up charts with rather benign complaints, only to fall into a vortex of trouble. As it turned out, Mr. B.'s legs were rather edematous, and gout did not seem to be the culprit.

“How long have your legs been this swollen?” I asked.

“Pretty long now. Dr. S. said they're getting worse,” Mr. B. said.

Dr. S.? He was a nephrologist.

“Why do you see Dr. S.?” I asked.

“He told me I need the dialysis, but I don't want it,” Mr. B. said.

When I first met Mr. B., he seemed affable and cooperative. He wore a T-shirt with one of those sayings, something like “World's Greatest Grandpa.” Once the subject turned to dialysis, his face hardened, and a steely reserve rose to the surface.

“You need dialysis?” I asked him.

“Might need. But I'm not going to do it, ever. I'd rather die,” he said.

At that point, Mrs. B. uttered words of frustration, and a longstanding argument was about to be rehashed. We decided to check some blood tests before the words became too heated.

The results were not good. Mr. B. was in renal failure, with a blood urea nitrogen level over 100 and a creatinine level of 11. His potassium level was over 6.

A call to the on-call nephrologist followed, with plans for emergency dialysis. The physician covering for his nephrologist suggested we get a surgeon to put in a Quinton catheter that night. By serendipity, the on-call surgeon happened to be sitting in the emergency department after finishing a consult. All the pieces were in place. Now—to talk with Mr. B.

Oftentimes complex treatment strategies are developed by making multiple phone calls, cajoling and pleading with consultants, and making logistic arrangements. An elaborate scheme of care gets constructed, and the patient is the last to be informed. So many things need to be set up in such little time that informing the patient becomes a last step, a formality. When the patient doesn't go along with this well-constructed scheme, all plans go for naught, and it's certainly a rude awakening.

Mr. B. was informed he was in renal failure, his potassium was dangerously elevated, and he needed emergency dialysis. He refused (but surely he would see the wisdom of my treatment plan). Affability had become defensive resistance, and the battle began.

The facts about indications and risks were explained again. He refused again. The appeal to sentimentality then ensued—think of your family, your grandkids, and how they need you alive and well. He refused. His wife, who cannot be described without resorting to the cliché “long-suffering,” pitched her case as well. Her pleading began with an appeal to reason, then shifted into an angry monologue. She told me about their many visits to different medical centers. Each time Mr. B. was told he needed dialysis. Each time he refused, and she had reached her limit. Disgusted with his stubbornness, she walked out of his room repeatedly to collect her thoughts.

But why, we asked, why do you refuse?

“Everyone knows the black people and poor people get put on dialysis, and the white patients get transplants,” he answered.

I can be naive. I'd like to believe the doctor–patient relationship exists in some pristine universe where the two work together to help the patient recover or maintain health. Shades of skin do not matter, money in the pocket does not matter, gender does not matter. Idealism has a way of crashing head-on with reality, and this was one of those moments. Mr. B. most likely saw me not as a physician caring for him but as a shade of white, a voice of institutional racism—the enemy.

The notorious history of racism in medicine cannot be denied. There was some epidemiologic truth to Mr. B.'s assertion. But this was not the time for a public health forum. His wife quickly shot down his argument, in a way that had more moral authority than the words of a white emergency physician.

“You need dialysis now,” she urged, “even if you get a transplant later.”

By now the surgeon had decided to leave. The on-call nephrologist arrived, a woman of Indian descent. He would have nothing to do with dialysis, he said, no matter what she advised. We decided to treat him best as we could with Kayexelate and changed his anti-hypertensives. He refused dialysis and admission. Mr. B. appeared to have decision-making capacity, despite his uremia. He signed out against medical advice, not much better than when he came to the emergency department.

Several weeks later, I spoke to the nephrologist about a different patient.

“Remember Mr. B.?” she asked. She said she saw him up in the intensive care unit last week—on dialysis.

How in the world did they get him to consent? She told me Mr. B's nephrologist put him on the telephone with an African-American nephrologist in Washington, DC. It was only after speaking to that nephrologist that he consented.

“How did he look?” I asked.

“Miserable, but he was alive,” she answered.

Bonnie Salomon, MD

Lake Forest Hospital; Lake Forest, IL 60045