Blog — Clinical Spanish

Spanish for dialysis nurses: the patient who has been on the transplant waitlist for six years and asks if you think he will ever get a kidney, the question that is not a question about the waitlist, and the conversation that names what six years of waiting actually costs

Carlos Ibáñez is 67 years old. He has been on hemodialysis for six years, Monday, Wednesday, Friday. He was listed for a kidney transplant the year he started dialysis. He is blood type O positive. He has been on the waitlist for seventy-two months. Every three months, the transplant coordinator calls to say she is still working for him. Every three months, he says thank you.

What Carlos has not said yet

Carlos came to the United States from Jalisco in 1989. He worked in construction for thirty years. He retired in 2019 because of the dialysis. His wife Esperanza died in 2021, one year into the pandemic, from a stroke. His daughter Marisol lives forty minutes away. She comes to the unit sometimes on Wednesdays.

Carlos has been in this chair Monday, Wednesday, Friday for six years. He knows the staff. He knows which machine has the loose armrest. He knows which shift changes run late and which nurses bring coffee and which ones don’t. He is the patient who asks about the staff’s families, who remembers the names of children, who makes the unit feel, on its good days, like a place that is used to him being there.

In October of last year, he attended his nephew Ricardo’s wedding. The reception was on a Saturday afternoon in a rented hall in Pomona. There was food and there was music and there were relatives Carlos had not seen since Esperanza’s funeral. At some point in the reception — he does not remember exactly when, somewhere between the cake and the last dances — Carlos found himself standing near the edge of the dance floor doing arithmetic.

O positive. Median waitlist time in his region: five to seven years. He has been on the list six years. He is 67. If the kidney comes in the next year, he will be 68. The transplant team has said there is no strict age cutoff, that they evaluate each case, that his overall health outside the kidneys is reasonable. But Carlos has also heard what the coordinator does not quite say in those conversations. He has heard the word “evaluation.” He has heard the phrase “we’ll see how things look.”

He did not dance at the wedding. Not because he couldn’t. Because the arithmetic had gotten into the music and wouldn’t leave.

On a Wednesday morning in June, while the nurse is connecting him at seven o’clock, Carlos looks at her and says:

“¿Usted cree que alguna vez me van a dar un riñón?”

Failure mode 1: The nurse who answers the waitlist question

The nurse who hears “¿usted cree que alguna vez me van a dar un riñón?” and goes to the clinical answer is not wrong that there is a clinical answer. She knows Carlos is O positive. She knows O positive is the group with the longest median waitlist time because O positive recipients can only receive from O positive donors. She knows about the PRA and the panel reactive antibodies and how sensitization from prior exposures narrows the compatible pool. She knows that six years is within the normal range for his blood type in his region and that the statistics do not say the wait is hopeless.

The flat answer:

“Pues, sr. Ibáñez, depende de varios factores. Su grupo sanguíneo es O positivo, y eso hace que la espera sea más larga porque necesita un donador del mismo tipo. Además está su PRA, que afecta cuántos riñones son compatibles. Pero sigue siendo un candidato, y el equipo de trasplante sigue trabajando para usted.”

(Well, Mr. Ibáñez, it depends on several factors. Your blood type is O positive, and that makes the wait longer because you need a donor of the same type. There is also your PRA, which affects how many kidneys are compatible. But you are still a candidate, and the transplant team is still working for you.)

Carlos already knows this. The coordinator has explained it. The nephrologist has explained it. He has looked it up. He did not ask because he had forgotten what O positive means on a waitlist.

He asked because it is June and he has been waiting six years and he spent his nephew’s wedding reception doing arithmetic at the edge of the dance floor.

The clinical answer answers the question Carlos did not ask. The nurse who delivers it accurately has told Carlos nothing he did not know and has heard nothing that Carlos came in carrying.

He nods. He thanks her. He does not ask again.

Failure mode 2: The false reassurance that closes the door

The second failure mode is the opposite of the first. It is not clinical; it is kind. And it is still a failure.

“No se preocupe, señor Ibáñez. Usted lleva en la lista seis años y eso quiere decir que su turno está más cerca. Ya va a llegar.”

(Don’t worry, Mr. Ibáñez. You have been on the list for six years and that means your turn is getting closer. It will come.)

The nurse who says this is trying to give Carlos comfort. She is not lying, exactly — it is true that waiting longer accumulates points in many allocation systems, that six years of dialysis represents a real investment in the waitlist. And she is not trying to dismiss him.

But “ya va a llegar” closes the door without meaning to.

It tells Carlos that the correct response to what he is feeling is to not feel it, or to feel it less, or to direct it toward a future event that the nurse has now guaranteed even though she cannot guarantee it.

It does not give Carlos permission to say that he sometimes wonders whether the kidney will come before he is too old or too ill to survive the surgery. It does not give him permission to say that he spent his nephew’s wedding reception doing math instead of dancing. It does not give him permission to say that Esperanza died waiting and that he thinks about that sometimes on Wednesdays.

So he does not say any of it.

He says “ojalá” and looks at the machine.

Failure mode 3: The conversation that does not name what is in the room

The third failure mode is subtler than the first two. It is the conversation that acknowledges Carlos’s question, that does not go straight to the statistics, that does not offer false reassurance — but that also does not name what is actually in the room.

What is in the room is that Carlos is 67. That he has been on dialysis for six years. That his wife died. That he attended a wedding last fall and spent it at the edge of a dance floor doing math. That he is asking the nurse who connects him on Monday, Wednesday, and Friday — not the coordinator, not the nephrologist, not his daughter — because he has decided she is the one who will sit with him in the actual question.

The failure mode that does not name this looks like presence without actually arriving.

“Sr. Ibáñez, entiendo que la espera es difícil. Es normal sentirse cansado. Si quiere, puedo hablar con su coordinadora para que lo llame esta semana y le dé una actualización sobre dónde está su caso.”

(Mr. Ibáñez, I understand the wait is difficult. It’s normal to feel tired. If you want, I can speak with your coordinator so she can call you this week and give you an update on where your case stands.)

The coordinator referral is correct. It is useful. Carlos should have that conversation.

But “es normal sentirse cansado” names the surface of what Carlos is carrying and then moves away from it quickly. It manages the feeling rather than staying with it.

Carlos is not tired. Or not only tired. He is 67. He has been waiting six years. He has done math at a wedding. He has a question underneath the question that none of these three responses has let him ask out loud.

The question underneath the question is: is the kidney still coming for me, or am I the kind of patient for whom the kidney comes too late?

He has not said it. He has said “¿usted cree que alguna vez me van a dar un riñón?” He is waiting to see if the nurse will let him say the rest.

The conversation that works: opening instead of answering

The nurse who hears Carlos’s question correctly does not hear “explain the waitlist to me.” She hears “I am asking you something and I am choosing to ask you specifically.”

She finishes securing the connection. She does not rush. She says:

“Sr. Ibáñez — esa es una pregunta grande para las siete de la mañana. ¿Me puede decir un poco más sobre qué lo hizo pensar en eso hoy?”

(Mr. Ibáñez — that is a big question for seven in the morning. Can you tell me a little more about what made you think of it today?)

She does not fill the pause.

Carlos may answer with something practical. He may say the coordinator called last week and he has a question about what she said. In that case, the conversation is about logistics and the nurse can help with that.

But Carlos may say something else.

He may say “es que mi sobrino se casó en octubre y me di cuenta que estuve pensando en la lista toda la recepción.”

(It’s that my nephew got married in October and I realized I was thinking about the list the whole reception.)

Or he may say “llevo seis años esperando y a veces pienso que para cuando llegue ya voy a ser muy viejo.”

(I have been waiting six years and sometimes I think that by the time it comes I will already be too old.)

Or he may say nothing for a moment and then say “mi esposa murió esperando. No el trasplante — ella no estaba en la lista. Pero murió esperando que pasara la pandemia. A veces pienso en eso.”

(My wife died waiting. Not the transplant — she wasn’t on the list. But she died waiting for the pandemic to pass. Sometimes I think about that.)

Whatever Carlos says, the nurse does not move away from it.

If he says he was at the wedding doing math:

“Eso es mucho peso para llevar a la boda de su sobrino. Tiene sentido que se pregunte eso. Seis años esperando es mucho tiempo, y usted tiene 67 años — lo que está sintiendo no es ser negativo. Es que usted está siendo honesto sobre lo que le importa y lo que le preocupa. Y eso es exactamente lo que el equipo de trasplante necesita saber.”

(That is a lot to carry to your nephew’s wedding. It makes sense that you wonder about that. Six years of waiting is a long time, and you are 67 — what you are feeling is not being negative. It is being honest about what matters to you and what worries you. And that is exactly what the transplant team needs to know.)

If he says he worries he will be too old:

“Esa es una pregunta legítima. No hay una regla simple sobre la edad, pero sí hay una conversación que merece tener con su coordinadora y con el equipo de trasplante — no sobre si usted ‘ya pasó’, porque eso no es cómo funciona, sino sobre dónde está su caso ahora mismo, qué tienen en cuenta cuando llega un riñoacute;n compatible, y qué significa eso para usted en los próximos años. Eso es una conversación que se la merece, y que yo puedo ayudar a que pase esta semana.”

(That is a legitimate question. There is no simple rule about age, but there is a conversation you deserve to have with your coordinator and the transplant team — not about whether you have “aged out,” because that is not how it works, but about where your case stands right now, what they take into account when a compatible kidney arrives, and what that means for you in the next few years. That is a conversation you deserve, and one I can help make happen this week.)

The transplant coordinator handoff: framing matters

Carlos’s transplant coordinator is the right person to give him a specific, honest update on where his case stands. She knows his current PRA. She knows how many compatible kidneys have passed in the last year and why they were not allocated to him. She knows what his position on the list looks like relative to other O positive recipients in the region.

The dialysis nurse does not have this information. Acknowledging that honestly is not the same as dismissing Carlos.

The framing that closes the door:

“Eso realmente es una pregunta para su coordinadora de trasplante. Yo no puedo responder eso.”

(That is really a question for your transplant coordinator. I can’t answer that.)

What Carlos hears: not here, not me, not now.

The framing that opens the door:

“Su coordinadora tiene información que yo no tengo — su posición exacta en la lista ahora mismo, cuántos riñones compatibles han pasado y por qué no fueron para usted, cómo está su PRA en este momento. Yo no tengo acceso a eso, pero ella sí. Y creo que usted merece tener esa conversación — no en tres meses cuando ella lo llama de rutina, sino esta semana. Lo que sí puedo hacer es hablar con el equipo para que esa conversación pase pronto. ¿Le parece bien?”

(Your coordinator has information that I don’t have — your exact position on the list right now, how many compatible kidneys have passed and why they were not for you, how your PRA stands at this moment. I don’t have access to that, but she does. And I think you deserve to have that conversation — not in three months when she calls you on the routine check, but this week. What I can do is speak with the team so that conversation happens soon. Does that sound okay?)

The difference is not the content. The difference is whether the nurse is framing the referral as something she is arranging or something she is offloading.

“Yo puedo hacer que eso pase” keeps the relationship intact. “Eso es para su coordinadora” ends the conversation.

The palliative care conversation the dialysis unit almost never has

There is a third conversation that may belong in this session, depending on what Carlos says.

If Carlos says he is worried about being too old, or that he is not sure the wait is still worth it, or that he thinks about Esperanza and about waiting, there is a team whose job it is to have exactly this conversation.

Most dialysis patients who have been on the transplant waitlist for six years have never met the palliative care team. Not because they are not appropriate referrals. Because “palliative care” in the US context is associated with dying, and neither the patient nor the team is ready to name it that way.

But a palliative care conversation for a 67-year-old who has been on dialysis for six years and is six years on the waitlist is not a conversation about dying. It is a conversation about what Carlos wants his life to look like in the next few years if the kidney does not come on the timeline he has been imagining, whether dialysis will still feel worth it the way it does now, whether there are things he has been putting off until after the transplant that he might want to stop waiting for, and what the team should be working toward for him beyond the waitlist.

The nurse does not name it as palliative care first.

She names it as a conversation about what matters most.

“Sr. Ibáñez, hay algo que me gustaría mencionar si me lo permite. Hay un equipo en el hospital — no son los médicos de trasplante, no son los neófrólogos — que se especializa en hablar con los pacientes sobre qué es lo que más les importa para su vida y para su cuidado. No es un equipo de ‘rendirse’ — es un equipo que ayuda a los pacientes a pensar en voz alta sobre lo que quieren, y a asegurarse de que el equipo que los cuida está trabajando hacia lo que realmente importa. Muchos de nuestros pacientes que llevan años en diálisis dicen que esa fue la conversación más útil que tuvieron con alguien del hospital — no porque les dijeran algo malo, sino porque por fin pudieron decir en voz alta lo que ya estaban pensando. ¿Es algo que le gustaría explorar?”

(Mr. Ibáñez, there is something I would like to mention if you’ll allow me. There is a team at the hospital — not the transplant doctors, not the nephrologists — that specializes in talking with patients about what matters most for their life and their care. It is not a “giving up” team — it is a team that helps patients think out loud about what they want, and to make sure the team taking care of them is working toward what really matters. Many of our patients who have been on dialysis for years say that was the most useful conversation they had with anyone at the hospital — not because they were told something bad, but because they were finally able to say out loud what they were already thinking. Is that something you would like to explore?)

Carlos may say no. He may not be ready for that conversation yet.

That is fine. The nurse has named that the team exists and that it is available to him without framing it as something he needs because he is running out of time. He will remember that it was offered.

He may say yes.

In that case, the nurse makes a note and the palliative care team schedules a visit for the next Wednesday session.

Lo que Carlos le preguntó a la enfermera

On the Wednesday afternoon three weeks after the June conversation, Carlos tells the nurse that he spoke with his coordinator. She gave him an honest update: his current position on the regional list, the two compatible kidneys that had been offered and declined in the past year (one for medical reasons, one because he had an active infection at the time), his updated PRA, and a realistic estimate of what the next two years look like.

The news was not uniformly good. The coordinator told him that O positive transplants in his region are running five to eight years median waitlist time and that his age will be taken into account in the allocation decision in ways she wanted him to understand. She also told him two compatible kidneys had been offered in the last year. He had not known that.

“Me dijo cosas que no me había dicho antes,” Carlos tells the nurse. (She told me things she hadn’t told me before.)

The nurse says:

“¿Cómo se quedó con todo eso?”

(How did you end up feeling about all of that?)

Carlos thinks for a moment.

“Mejor,” he says. (Better.) “Aunque las noticias no son perfectas. Pero me siento mejor.” (Even though the news is not perfect. But I feel better.)

“¿Por qué mejor?”

“Porque sé lo que está pasando. Antes no sabía. Solo esperaba.”

(Because now I know what is happening. Before, I didn’t know. I was just waiting.)

The nurse who asked “¿qué lo hizo pensar en eso hoy?” at seven in the morning in June is the nurse whose question made the coordinator conversation possible.

Carlos did not need a new waitlist position. He did not need different statistics. He needed someone to let him say what he had been carrying since October so that he could finally tell it to the person who could actually answer the specific questions underneath it.

The question “¿usted cree que alguna vez me van a dar un riñón?” was never about the waitlist. It was about whether the nurse would stay with him long enough to hear what he was actually asking.

She did.

He asked again on Wednesdays. Not the waitlist question — a different kind of question. The kind a person asks when he believes the room is safe enough to ask it.