The year was 1943. As a third-year medical student at Stanford, I was about to witness the beginning of a medical miracle. Dr. Arthur Bloomfield, Professor of Medicine, had selected my patient, a middle aged man, who was dying of acute pneumococcal pneumonia, as one of the first patients to receive miniscule doses (by today's standards) of his meagre supply of a new drug - penicillin. The patient's response amazed everyone especially this impressionable medical student. The rest of the story is history. With one stroke, the introduction of penicillin removed from the medical scene the 'friend of the aged' - lobar pneumonia. The consequences, which no one could have imagined at the time, are still becoming manifest as other 'miracles' such as respirators, artificial kidneys and many potent new antibiotics have come upon the scene. All of us are aware that these miracles have created a variety of new challenges around the states of dying and near dying. We have no easy answers for these problems.
Nevertheless as dialysis techniques, especially CAPD, are applied more widely to the treatment of the elderly, the task of helping the patient meet death with dignity becomes increasingly important and vexing because once begun, dialysis is difficult to terminate.
1. Introduction.- 2. Physiology of Aging.- 3. Senility and Maturity: Psychosocial Aspects of Aging.- 4. Pharmacokinetics and Pharmacodynamics in the Elderly.- 5. Fluid and Electrolyte Disorders in the Elderly.- 6. Sodium Homeostasis with Special Reference to Fractional Excretion of Sodium and Plasma Prostaglandin E-1 in Elderly Hypertensives in Essential and Renovascular Hypertension.- 7. Aging and Body Water.- 8. End-Stage Renal Disease in the Elderly A Geriatrician's Viewpoint.- 9. Decline of Renal Function with Age: Mechanisms, Risk Factors and Therapeutic Implications.- 10. Preventable Causes of Renal Failure in the Elderly.- 11. Bacteriuria in the Elderly Subject; Its Relationship to Survival.- 12. Acute Renal Failure in the Elderly.- 13. Chronic Renal Failure in the Elderly.- 14. Nutritional Needs for the Elderly Hemodialysis Patient.- 15. Hemodialysis of the Elderly.- 16. Peritoneal Dialysis in the Elderly.- 17. Renal Transplantation in the Middle-aged and Elderly Uremic Patient The Recent United States Experience and Results from a Single Institution.- 18. Renal Transplantation in the Elderly: The Canadian Experience.- 19. Nursing Aspects of the Elderly Patient on Dialysis.- 20. The Elderly Patient on Dialysis-Psychosocial Considerations.- 21. Refusal or Termination of a Life-Support Program - Legal Aspects.- 22. Uremia in the Aged: Can we Afford to Treat Everybody?.- 23. Can we Afford to Treat Everybody? The UK View.- 24. It is Happening Here.- Discussions.