It was Saturday morning. I was a little bit late and went straight to the morning report session instead of my office.
The intern was presenting a 19-year-old girl who had been referred to our center from a small city in northern Iran. She had felt pretty healthy until a couple of days earlier, when she developed dyspnea and went to the hospital. Due to a bilateral pleural effusion and a creatinine of 10 mg/dL, she was immediately referred to another center.
The case was discussed thoroughly in the session. There was no obvious cause for the renal failure, and the kidneys were small — indicating a chronic process rather than an acute one.
I was thinking about the case during the long walk from the Morning Report Hall (in the old building) to the 13th floor in the new building, where the general internal medicine wards are. I had some new patients to visit. And there she was — the first new patient presented by my resident.
A teenager with light brown hair and light eyes, with the kind of peculiar smile you see on people who are joyful and grateful.
More history was taken. Some tests were requested. But something was obvious. Her kidneys were small and fibrotic. They were not going to be healthy again. So, she indeed needed dialysis.
So, how do you tell a cheerful young girl — who is feeling better after her first dialysis session — that she needs dialysis permanently? Bad news isn’t just about cancer.
And the alternative? Transplant. But it’s not that simple — her heart was weak too. So it first had to be determined what exactly was wrong with the heart. Was it permanent or temporary? If permanent, a combined heart-kidney transplant would be needed.
I repeated the sonography for two reasons. First, there was a suspicion of renal artery stenosis, and second, I wanted to confirm the kidneys’ appearance. It confirmed small, damaged kidneys, and that there was nothing wrong with the renal artery.
So now it was time.
I talked to her about her kidneys. At first, I didn’t bring up the heart problem completely, so as not to complicate the issue further. Her family (brother, mother, grandmother, and father) was present too. She started crying once she heard that dialysis would have to continue.
I don’t know the perfect way to break the news. I don’t even know if a perfect way exists.
When breaking bad news, strong emotions are expected. But I never know what to do next. I know saying “I understand” is kind of silly. How can I understand, for example, going three times a week to a dialysis unit? I can only assume that it’s hard.
I just assure them that I’m there, and that if they have any questions, I’m here to answer them — and then I let them think. I don’t try to sugarcoat it. I don’t try to downplay it. It’s difficult. It’s life-changing.
It’s okay to not feel okay after this. It takes time to adapt. And in the end, no matter how hard it is, we adjust and adapt, and we continue.
She asked about the alternative. I told her about the transplant. The family asked about the worst-case scenario. I told her parents — in private — about the combined transplant, and about the waiting period: the hardest and most ambiguous part, waiting to see whether her heart would recover once the uremic toxins were cleared by dialysis.
But she wasn’t fond of the idea of a transplant. For now, it wasn’t the right thing to try to persuade her. She already had too much to think about and process. I told her we’d talk about the transplant later, and I asked her to tell me what her concerns and fears about it were.
I remembered one of my professors saying, about a similar patient: let the patient experience dialysis for a couple of weeks, let her see that it’s not easy, and then she’ll eagerly want a transplant.
