DOWN THE DRAIN
As with most of life's compromised situations, dialysis patients face an ultimatum, rather than a choice. But how able they can pay their way through the borrowed time may spell a quality-of-life difference.
By Grace Roxas, Contributing Writer
While most folks his age would tend to hear niceties about their youthful looks from friends and colleagues, 69-year-old journalist Eduardo Lacson doesn't mind that people would rather comment how he doesn't look like someone who's been on renal-replacement therapy for more than five years now.
Still active in his profession as senior editor for Business Mirror, Ka Eddie represents what many in this part of the world would deem unthinkable: a dialysis patient living a highly functional life.
But he's been lucky, and he knows it. A big part of it is having an internationally respected nephrologist for a son (Dr. Eduardo Lacson Jr.) who was able to monitor his condition with a filial concern no professional thoroughness can match.
The elder Lacson was able to get artificial organ support before his kidney function gave out entirely, and the mode of therapy he chose, peritoneal-renal-replacement therapy, allowed not only the closest simulation of normal organ function but a more flexible lifestyle.
Another part of his good fortune is having the means, through his gainful employment and assistance from his children, to sustain what would be quite a backbreaking financial burden for most other Filipino renal-failure patients.
As a peritoneal-therapy patient, Lacson belongs to only 10 percent of Filipino dialysis patients who have access to this more convenient but costlier (in terms of up-front cost at least) form of renal-replacement therapy. He spends an average of PhP40,000 a month just for the purchase of the dialyzer solutions that he himself administers for 30 to 45 minutes, at least four times a day.
He has his senior-citizen discount to thank that he's not paying more. At the start, he was actually shelling out around PhP60,000, a princely sum equivalent to several months' pay check for many middle-class Filipinos.
The government, through agencies such as the Department of Social Welfare and Development and the Philippine Charity Sweepstakes Office, offers discounted peritoneal dialysis on a limited basis. The therapy can be had for as low as PhP20,000 for patients who qualify as indigents.
This rate is competitive with that of hemodialysis, the more popular and cheaper mode of renal-replacement therapy in the country, but is sadly still beyond the means of the very patients who are economically depressed enough to pass the government's criteria for assistance.
Complicated reality
Not yet captured by these numbers is the complicated reality of physiological vulnerability when you're sick enough to be having artificial kidney support.
"The devil is in the details. Actually, your minimum expense is for the dialysis solution. It all depends on what happens to your body.
Para kang bumili ng kotse. Akala mo yung hulog mong PhP10,000 per month and gasoline expenses are enough. But you don't know what else could happen when you're operating the car already," says Lacson.
Apart from the solution, he also has to spend for peripheral items like disinfectants, bandages, sterile gloves, and other paraphernalia to ensure that each dialysis session goes without a glitch.
Lacson found out the hard way that scrimping on these peripherals is fool's economy. A dangerous one at that. He tried cutting corners once and was subsequently hospitalized twice last year within a space of five months for infections.
His hospital ordeal-avoidable by the simple expedient of buying sterile gloves costing less than PhP10 a pair-not only stripped 10 kilos off his weight but set him back around PhP100,000. Again, the amount was already a bargain from the PhP250,000 he would have spent if he were confined in a private hospital instead of the National Kidney and Transplant Institute and if he were without his health-insurance coverage.
He was not the first, nor will he be the last dialysis patient who tried economizing in the wrong places with grim results.
In a country where many patients go for institution-based hemodialysis therapy because the up-front cost can be lower by half compared with that for the peritoneal mode, the belt-tightening doesn't stop with just opting for cheap.
Just as penny-pinching sick people in general would tend to buy only half-prescriptions of medicines they need, there are dialysis patients who underdialyze for the same reason.
The cheapest hemodialysis rate ranges from PhP1,600 to PhP1,800 per session for procedures that include reuse of the dialyzer. If the prescribed frequency of dialysis is thrice a week for example, and spending PhP1,600 three times a week for a month is a bit out of a patient's budget range, he would go only twice or even once a week.
Not infrequently, they underdialyze their way to serious complications that would cost them at least thrice the amount they tried to save, in addition to losing what remains of their kidney function. If no money is to be had for the bigger outlay that hospitalization entails, then things had to take their sad but all-too-predictable course.
For kidney-failure patients with serious comorbid conditions like diabetes-and they comprise 70 percent of cases-the risk for hospitalization is a sword hanging by a thread over their heads. They may even have to set an annual budget for hospital confinement.
At the very least, one needs to allot for medicines to handle physiological fluctuations-like high cholesterol and low blood pressure-that become more pronounced when the body is compromised by kidney failure and by the rigors of the dialysis itself.
Quality of life, hidden costs
Hemodialysis, especially as practiced in the Philippines, is the more rigorous form of therapy. Unlike in developed countries where people can afford to have it daily, Filipino patients, including the relatively well-off, can only avail themselves of it here every other day at the most. This means that the therapy is necessarily more aggressive, subjecting the body to a tougher pummelling compared with the milder action of a daily procedure.
How this affects the patient's circumstances is at the core of arguments that-in the Philippines at least-the "hidden costs" of hemodialyzing more than offset the more expensive price tag of peritoneal dialysis.
A daily therapy would have minimal side effects like vomiting, dizziness, and general debilitation, thus leaving the patient more independent and even productive enough to work and pay for at least part of his treatment.
Even for hemodialysis, it is possible for patients to structure their schedule so that work is still possible. In the US, notes Lacson, hemodialysis patients can have their two-hour daily procedure after work so they can sleep off the side effects during the night and be back for work the next day.
On the other hand, patients who only go for twice- or thrice-a-week sessions-lasting an average four gruelling hours-would need at least the whole day to recover. And they can't go through the whole thing alone, so they either have to pay someone or have a relative take time off work and other gainful pursuits to accompany them, as is usually the case in the Philippines.
Ed went through hemodialysis when he was hospitalized and he couldn't imagine how those who go through it can still work. "Nabubugbog ang internal organs that's why you have to rest
kahit akala mo okay ka na. Pag nagtrabaho ka, baka matuluyan ka. Magkasakit sa puso or stroke," he says.
He also lost a lot of blood because of a clotting problem and almost got into a driving accident during a dizzy spell after a particularly draining procedure.
Although Lacson knows of many hemodialysis "veterans" who have adjusted quite well to this mode of therapy, the experience steeled his resolve not to risk his body's ability again to handle peritoneal therapy. Damage to the peritoneum through infection would disqualify a dialysis candidate from peritoneal therapy.
Lacson relishes not having any restrictions on what he eats and drinks (except the common caveat about moderation), being able to drive himself around and mostly making do without household help even at his advanced age.
And of course there's work, which he can now do equally well in the house as in the office, thanks to modern technology.
"Wala akong kakilalang hemodialysis patient who's still working. But the other patients are amazed that I'm still working.
Buti na lang, my three kids are at least earning well enough and since I have a job, it's not so hard for them because I can pay for my utility bills, food, and transportation," Lacson says.
He adds: "On the financial side, both kinds of therapy come out about the same in the end. If you are still able to do something with your life, like work and take care of your grandchildren, then the quality of life offered by peritoneal therapy is simply out of range of hemodialysis. But if you're old and retired already, then hemodialysis is okay so
mas relaxed ka na." M
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