For frail, elderly patients with advanced chronic kidney disease (CKD) who also suffer from multiple other ailing conditions, choosing conservative care with non-dialysis treatment and spending more time in the community or at home may be their preferred choice.
Although 84-year-old Ahamed has lower limb weakness, he becomes instantly mobile upon getting on his electric scooter. He can then swiftly make his way to the nearby market to buy his wife’s favourite breakfast.
Reaching his golden years, Ahamed is living his best possible life. Diagnosed with kidney failure in 2021, he had chosen the conservative non-dialysis treatment as he did not want his family to bear the burden of caring for a dialysis patient.
This treatment option is part of the Renal Conservative (Non-Dialysis) Care (RCC) Programme, a three-year pilot project launched in May 2021 between Sengkang General Hospital (SKH) and Tzu Chi Foundation (Singapore) for elderly CKD patients aged 60 and above.
This programme aims to provide better support to patients in the community, optimise their care to slow down kidney disease progression, and maintain their quality of life via a holistic approach to controlling symptoms. The programme also includes Advanced Care Planning (ACP) and timely transition to hospice care. Following assessment and referral by SKH, Tzu Chi community nurses will conduct routine home visits to the patients. As of December 2022, 68 patients have enrolled in the programme.
HOME VISIT NURSING CARE
At least once a month, a familiar figure, Tzu Chi community nurse Esther Koh will come knocking on Ahamed’s door. With a suitcase packed with the necessary medical supplies, she is ready to begin nursing care that afternoon.
Upon her arrival, Ahamed offered her coconut water, which she likes. He slowly got up from the sofa and made his way to the refrigerator to bring out the coconuts. He cut them open and served them. Subsequently, he retrieved erythropoietin (commonly known as a “blood booster”) from the refrigerator and a notebook where he records his blood pressure and blood sugar levels.
“I usually let them handle it by themselves,” said Ms Koh.
Although she was patiently sitting on the sofa while Ahamed got busy, she had been observing him since the moment she arrived — checking for swollen feet and whether he had any difficulties moving, among other observations.
Throughout the visit, Ms Koh and Ahamed conversed in Malay. “We must use the language that the patient is familiar with,” she shared.
Ms Koh, who is fluent in several languages, usually finds out about her patients’ physical condition, diet, lifestyle, emotional state and household financial situation through conversation. Whenever necessary, she refers them to medical services, social workers and psychological counselling services.
While chatting with Ahamed, Ms Koh took out a blood pressure machine, glucose meter and thermometer from her suitcase to measure his blood pressure, blood sugar level and body temperature. She then administered erythropoietin subcutaneously and carefully recorded her observations in a notebook. This data would later be transferred into the electronic medical record system.
“We will inform the doctor of any abnormally and he will then evaluate and recommend the appropriate action plan,” she explained.
AN ALTERNATIVE TREATMENT
Kidney failure, also known as end-stage kidney disease, occurs when kidney function is severely impaired, causing the build-up of toxins, waste and excess fluid in the body. In Singapore, 5.7 people are diagnosed with kidney failure every day, mostly those in their 70s and 80s living with chronic disease, just like Ahamed.
Common treatment options for kidney failure are haemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation. While Ahamed did not fully understand the similarities and differences between these treatments, he could clearly explain the reasons for not choosing them.
Initially, he was very resistant to going to the dialysis centre three times a week, for HD treatment that lasts four hours per session. As a person with mobility issues, he felt it would be a challenge. The doctor also assessed that he was not suitable for HD due to his weak heart and asked him to consider doing PD at home. Unfortunately, his poor eyesight meant that performing the PD procedures on his own would be tough. Moreover, his wife could not assist him as she has Parkinson’s disease.
When confronting declining health and physical function, and being unlikely to ever recover their kidney function, many elderly CKD patients such as Ahamed decided that they did not want to endure the suffering from sickness and burden of treatment.
According to the literature, frail, elderly patients with multiple diseases can only prolong their lives by one to two years after undergoing dialysis. Even though they might live longer, they might not wish to spend their remaining years living with a poorer quality of life.
Many patients have certainly benefited from the launch of the RCC programme but it has had to overcome its fair share of challenges.
“When implementing a new programme like RCC, it is common to encounter unforeseen issues that may require some tweaks and adjustments. Some of these include areas such as staff training, data collection and patient education. Making improvements will ensure smoother running of the programme moving forward,” said Tzu Chi RCC Project Lead Lai Mee Horng.
Given the limits of dialysis and the importance of administering appropriate treatment that aligns with the individual’s values and preferences, RCC could be a viable alternative, one that can allow terminally ill patients to continue living with dignity and a good quality of life for their remaining days.
Photos: Tzu-Chi Foundation (Singapore)