The nutrition our patients need

The patient loved dill pickle-flavored potato chips. No matter how many times we reminded him that the excess salt would do his already failing kidneys no good, and no matter how many times we explained this to his wife—who otherwise could articulate his medical status better than he could and was the primary reason that he had agreed to stay in the hospital as long as he already had—we would walk in to find another bag of pickle-green chips sitting by his bed.

Aghast, we would tell him that he could eat the salty food he craved after we completed his treatment for hepatorenal syndrome.

And after we completed a second round of treatment when it returned with a vengeance only a few days after his kidney function had seemingly improved.

And after we kept him in the hospital for several more weeks, waiting for his kidney function to improve since sending him home after several months of hospitalization, far out into the countryside, when his wife had to beg and plead with him to see the doctors at all the first time, into the waiting arms of the mountains of dill pickle-flavored potato chips we imagined his house to be brimming with, would not lead to a good outcome.

But the patient continued to ask for the food he liked.

He had lived over 70 years, he told us, and not once during those 70 years had someone taken his dill pickles away from him, no sir.

He had tolerated the past several months of terrible, low-sodium hospital food, despite his daily hair-yanking frustrations of being told that he couldn’t order this, or that, or any of those things and had to content himself with foods he didn’t recognize, merely lifting the plastic lid and allowing the food inside to speak for itself; of being stuck and poked at odd hours of the day when we sent for labs; of being cooped up in a hospital room and having to be told every day that, hey, at least he had a good view! Of cars, asphalt, and the same unchanging buildings.

So, he told us as he eyed the pickle-green bag that we had moved from his bedside to the far counter, it didn’t seem like we were doing much for fun. That was the plan, eh? For him to lie here doing squat for the next how many weeks until his kidneys—he made an explosive noise with his mouth, accompanied by jazz hands—and we put him on dialysis.

Well, yes, we tried to explain. It was for his safety.

So, couldn’t he go home and wait there, if his kidneys were going to—he made that same explosive noise again, though his jazz hands seemed more wilted than before. Whatever meds we’d pumped him with for that liver-kidney whatever-ya-call-it hadn’t done anything, and he’d had that big ole tube sticking out of his neck for days ’cause of it, and he’d gotten tired of all this.

Well, no, we tried to explain, intern nervously wringing his hands, attending the picture of calmness despite the sweat beading on her brow. For his safety, since if he went home and waited until he felt sick, he might have not been able to get to a hospital in time before he—

The intern said, “Before you get very, very sick, maybe beyond help”.

The attending put her hand on the corner of his bed. “Before you don’t have a good outcome. Do you understand?”

“I sure understand”, he said, “but you know something funny? Being here all these weeks...this is the worst outcome there could be”.

We asked him to call his wife, if he would. He obliged. We elaborated on the situation again. She pleaded with him to stay in the hospital for just a little longer, and yes, she could bring him a bag of his beloved dill pickle-flavored potato chips—wouldn’t that make his stay just a little more comfortable?

He sighed. Okay. He would stay for one more day.

The resident, who had stayed mostly quiet during these visits, lowered her clipboard. “How would you feel if we took off that diet restriction? Let you eat whatever you wanted while you were here. Would that help, do you think, with staying longer?”

The attending thoughtfully touched her chin. And the patient, himself, smiled for the first time in several days. “That does sound”, he said, “mighty amenable”.

The resident continued. We would remove the diet restriction. We would speak with the nurse about allowing him to spend some time outside every day as long as he returned. We would—yes, we couldn’t allow him to smoke in the hospital’s walls, but if he happened to be outside, well, no one here would stop him, now would they?

It took several days to work things out. To have dining stop calling us back, concerned that a patient with his renal function couldn’t have foods with so much sodium and potassium. To have nurses not page us frantically when he spoke about going outside for a sit and a smoke. To have everyone on the same page for the accommodations we’d offered him.

But safer eating, and walking, and smoking where we could support him, than having kidney failure at home, or be upset at the hospital.

So, the patient stayed. He stayed; his renal function worsened; he was transferred for dialysis.

When we spoke to him on the day before a different team took over, wishing him the best in his transition, he was smiling, hands punctuating his words, coloring his speech with an entire smorgasbord of sound effects, hoping that the next care team would be as humane as we’d been towards him.

In his lap sat an open bag of dill pickle-flavored potato chips.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Paul Rousseau) for the series “The Human Experience” published in Annals of Palliative Medicine. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-22-1284/coif). The series “The Human Experience” was commissioned by the editorial office without any funding or sponsorship. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.