A late referral who wants to wait
Mr. A, 62, was referred to the CKD clinic with an eGFR of 16 mL/min/1.73 m². He has type 2 diabetes and hypertension, works as a chef, lives alone, and is right-hand dominant. He says, "I'll deal with dialysis when I need it - my uncle was miserable on it." He has had several IVs and a right antecubital PICC line placed during a recent hospitalization. No vein mapping has been done, and he has no vascular access. He has no advance care planning documents. His insurance covers only the providers in your network, and he has no one who can drive him to appointments.
1. What are your first three actions at this visit, in priority order, and why in that order?
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1. Protect his future access options before anything else. A right-arm PICC in a right-hand-dominant patient with eGFR 16 is a threat to the vein he will most need. Place a vein-preservation order, educate ward and lab staff, and request that the PICC be evaluated for removal or relocation with the treating team. This is time-critical because vein damage is irreversible; education can be repeated, veins cannot.
2. Start kidney failure treatment option education now - not a single recommendation for dialysis. At eGFR 16, an AV fistula needs roughly 3–6 months to mature, so "waiting" is itself a decision with a deadline. Educate on the full menu: in-center HD, home HD, peritoneal dialysis, preemptive or early transplant listing, conservative management. Include his uncle's experience explicitly rather than talking over it - ask what specifically made it miserable, because the answer often identifies fears (needles, travel, loss of work) that have real solutions.
3. Refer for vein mapping and a surgical/access evaluation, and in parallel refer to transplant and to social work/financial counseling. Mapping informs whether an AVF, AVG, or PD catheter is realistic, and it must happen before he is symptomatic. Social work addresses the transportation and network constraints, which determine which modality is actually feasible for a man living alone who works shifts.
Order rationale: irreversible harm first (veins), then the decision that has a lead-time requirement (education), then the logistics that constrain the choice.
2. He repeats that he will wait. Using a specific conversational approach, describe how you would respond, what you would say, and what you would not say.
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Use motivational interviewing and shared decision-making rather than persuasion.
- Ask before telling: "What has made you want to wait?" and "What did your uncle's experience look like for you?" Reflect back what you hear: "So the fear isn't really dialysis - it's losing your work and being alone in it." This surfaces the real barrier and makes him a partner.
- Offer information neutrally, with permission: "Would it be okay if I shared one thing about timing?" Then: "An access takes months to be ready. If we start now, you keep the option of choosing; if we wait until you feel sick, the choice may be made for you - often with a temporary catheter, which carries the highest infection risk." That is a statement of consequence, not a threat.
- Correct the false binary: waiting does not mean doing nothing else. He can pursue transplant evaluation, protect his veins, learn home therapies, and still defer the final decision.
- Address the practical barriers concretely: the transportation problem and network limits may make home PD or a closer unit more attractive - naming that shows his constraints are being taken seriously.
- Introduce advance care planning as a separate, non-urgent conversation about what matters to him, not as a package with dialysis.
What I would not say: "You'll die without dialysis," "You have to decide today," or anything that dismisses his uncle's experience. Coercion produces disengagement and a crash start. Document that education was offered and declined, and set a specific date to revisit.
3. One week later his eGFR is 12, potassium 5.6, and he has nausea and 2 kg weight gain. What does your education plan become, and how do you confirm it is working?
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Shift from elective to urgent, and be honest about the change in timeline.
The situation has moved from "plan ahead" to "prepare now": potassium 5.6 with nausea and volume gain means uremic and hyperkalemic progression, and the risk of an unplanned start is rising. Education now narrows to what he can act on within days:
- Dietary potassium and sodium: specific, named foods - salt substitutes (potassium chloride), potatoes, tomatoes, oranges, bananas, dried fruit, and the stock and sauces he likely tastes constantly as a chef. Give swaps he can use in a professional kitchen, not just at home.
- Symptoms requiring immediate contact: vomiting that prevents eating or drinking, palpitations or muscle weakness, decreasing urine output, weight gain beyond the team's threshold.
- Access planning under time pressure: a tunneled catheter or urgent-start peritoneal dialysis may now be the realistic route if a fistula cannot mature; explain what that means and why it is chosen, rather than presenting it as a failure.
- Medication review: stop any potassium-containing or nephrotoxic agents, and arrange a repeat potassium per the team's plan.
Confirmation: teach-back on the three highest-risk items (which foods to avoid tonight, which symptom means call now, which number to call), plus a written plan posted in his kitchen. Objective measures over the next two weeks: potassium trend, weight, whether he keeps the scheduled access appointment, and whether he arrives without an emergency start. If teach-back fails or he misses appointments, escalate to a multidisciplinary huddle and consider a home visit or telehealth check-in rather than repeating the same handout.