Dialysis. The science of taking over the kidney's job in maintaining fluid / electrolyte / acidity balance in the body and removing waste. To those who don't know the ins and outs well, it is a magical cure to end stage kidney disease without any risk or effort. To us, it's a tough medical procedure with a lot of investment, for which a portion of patients are not suitable.

Haemodialysis (HD) is the science of removing a large volume of blood from the body via a fistula (a surgically-created tunnel that joins an artery to a vein), cleans it, and reinserts it. It exerts a significant amount of stress on the body because it takes a lot of blood out and then shoves back in a lot of blood. So it's not for people who have frail organs because it can literally cause you to get a heart attack or stroke. The general anaesthetic required to create it also means frail people won't get it done. HD is also very expensive and, in Hong Kong, not the first line treatment in the public sector because the system just can't afford it.

Peritoneal dialysis (PD) is using special glucose fluids to draw out excess waste, water, and electrolytes via a layer in the abdomen. It involves surgically inserting a catheter (a plastic tube) into the belly and then the patient has to put in about two litres of fluid three to four times a day into his belly and pour it out again after a few hours. Every single day. For the rest of his life. The patient has to keep the tubing clean because the glucose fluid is heaven for bugs and peritonitis (infection of the abdominal layer involved in peritoneal dialysis) has a high death rate. The PD fluids come in big bags, which take up a lot of space at home considering you use three to four bags a day every single day. There is no off day, no break, and it must be done daily.

So imagine your end stage kidney disease due to poor diabetes control, the patient is blind with diabetic neuropathy (diabetic nerve damage) so his fingers are numb. He can't see to attach the bag and ensure cleanliness. He can't feel the valves to ensure the tubing is attached properly. He doesn't know when the bag of fluid is infected to seek medical attention promptly. He doesn't have family members nearby who can help him with the fluid exchange four times a day. He has poor mobility, which means he can't get up to pour the fluid out of his belly. He is elderly, with an expected death in the next one or two years with or without dialysis. Patients like this are not suitable for dialysis because the procedure and future ends up being more trouble than it's worth. The patient may die earlier, but he has a better quality of life than constantly striving to maintain his dialysis and recurrent hospitalisations due to peritonitis because he can't see to keep things clean -- and peritonitis might kill him even earlier.

One patient swore up and down his brother would help him with PD once the tube is inserted. He isn't a good candidate; he doesn't have the dexterity to do his own PD and he lives in a small flat, which doesn't have space to hold the PD fluids. After several reviews, he claims his brother would let him move into his bigger house and do his PD for him. Once the tube is inserted, his brother disappears. The patient claims his flat is now too small for PD and he cannot be discharged until he gets a bigger home with money-that-does-not-exist so he needs the social worker to find him a bigger home. He doesn't have anybody doing PD for him so he cannot be discharged. He is stuck in a hospital for weeks.

One patient never wanted dialysis. He is old and frail. He wants to die without too many painful interventions. His daughter talks him into accepting PD. At some point, the tube gets blocked (which is not an infrequent occurrence). He requires temporary HD via a line in his neck until his PD tube gets unblocked. Meanwhile, he has further thoughts and decides to stop all dialysis. He is aware this means he will die earlier. His daughter refuses to accept his decision and is confident he only wants to stop because he's depressed due to being stuck in hospital. She feels we aren't doing our best for him because we refuse to force him to undergo something he doesn't want to. The clinical psychologist doesn't feel he's depressed and thinks he's in the right frame of mind. The patient refuses HD, which is meant to tide over until his tube gets fixed at a later date so he can resume PD. The patient says he never wanted dialysis in the first place so we need to stop. We are stuck in the middle.

Dialysis is a difficult topic with a lot of factors we need to consider. It's not simply a case of doctors deciding whether or not to extend someone's life when they've reached that stage. It's not for everybody.