Hemodialysis patients' experience with and attitudes toward the buttonhole technique for arteriovenous fistula cannulation.

BACKGROUND: the buttonhole technique for arteriovenous fistula cannulation has been recommended as an alternative to the rope ladder technique. AIM: we compared patients' experiences and hypothesized that patients would prefer the buttonhole technique. METHODS: in an observational cross-sectional study using a 23-item questionnaire, we surveyed hemodialysis patients at 3 dialysis centers who had previously used the rope ladder technique and were presently using the buttonhole technique for their experiences with and attitudes toward the two techniques. Twelve months later, patients' attitudes were reassessed. RESULTS: 26 patients met inclusion criteria. On a scale of 0 (not at all satisfied) to 10 (very satisfied), patients reported a mean satisfaction with the buttonhole technique of 8.5 ± 1.9. 96% of patients said they would recommend it, and 83% reported that the buttonhole technique was easier for the nurses to use. Fewer patients reported fistula infiltration with the buttonhole technique (12% vs. 59%, p = 0.008). Twelve months later, 18 of 23 patients (78%) still dialyzing in the study units remained satisfied with the buttonhole technique. CONCLUSIONS: patients reported a high level of satisfaction, fewer complications, and a positive attitude about suggesting the buttonhole technique to other patients. Our findings support the recommendation for its more widespread use.

Attitudes of patients toward cardiopulmonary resuscitation in the dialysis unit.

Some dialysis units have a policy of performing cardiopulmonary resuscitation (CPR) on all patients who experience cardiac arrest while undergoing dialysis. However, to perform CPR on patients who do not want it is contrary to ethics and the law. We interviewed hemodialysis patients in 12 units in Missouri, New York, and West Virginia to learn their attitudes about CPR. Four hundred sixty-nine of 830 patients (57%) agreed to be interviewed. Eighty-seven percent of patients wanted to undergo CPR if cardiac arrest were to occur while undergoing dialysis. Patients who had seen CPR on television were more likely to report that they knew what CPR was (94% versus 68%; P < 0.001) and to want CPR (88% versus 78%; P = 0.033). Thirteen percent of patients did not want CPR if cardiac arrest were to occur while undergoing dialysis. Compared with patients who wanted CPR, those who did not were older (69 versus 59 years; P = 0.026), had more comorbid conditions (2.0 versus 1.5 comorbid conditions; P = 0.016), and were more likely to have a living will (61% versus 43%; P = 0.01), be widowed (36% versus 20%; P = 0.026), and live in a nursing home (9% versus 3%; P = 0.017). Blacks were significantly more likely to want CPR than whites (adjusted odds ratio, 6.56; 95% confidence interval, 2.57 to 22.27). Only 20 of 58 patients (35%) who did not want CPR were certain they had a do-not-resuscitate order in their dialysis chart. Ninety-two percent of patients who wanted CPR agreed that patients who did not want CPR should have their wishes respected by the dialysis unit. We conclude that most dialysis patients want to undergo CPR, but also want other patients' preferences not to be resuscitated to be respected. Dialysis units need to do a better job of identifying patients who prefer not to be resuscitated and respecting their wishes in the event of cardiac arrest while undergoing dialysis. Most importantly, nephrologists and dialysis unit staff need to educate dialysis patients about the poor outcomes with CPR so that dialysis patients' decisions about CPR are informed.

The need for more physician communication with patients/families facing the end of life.

This six-step approach provides a framework for approaching communication at the end of life, communication that we know is very important to patients and families. This approach is not meant to be a rigid set of rules that must be followed in all cases, but it does present a list of what are usually the essential components of such conversations. The benefits of Buckman's approach include the following: Most patients and families want to know; Discussion of these issues strengthens the physician-patient relationship; The approach represents a compassionate way to engage the patient/family in a shared decision-making process; This communication fosters collaboration between the physician and the patient/family; and Communication of bad news permits the patients and families to cope with the reality of the situation and to plan appropriately for the future. All in all, this approach presents the opportunity for physicians and their patients to experience the best aspects of medicine, meaningful relationships that result from working through the patient's medical problems together.

Improving advance care planning by accommodating family preferences.

CONTEXT: Family members often lack the knowledge of patients' values and preferences needed to function well as surrogate decision-makers. OBJECTIVE: To determine whether differences in values and preferences for the advance care planning process may be reasons family members are inadequately informed to act as surrogates. DESIGN: Face-to-face and telephone surveys using structured questionnaires. PARTICIPANTS: Two hundred forty-two pairs of dialysis patients and their designated surrogates. MAIN OUTCOME MEASURES: Content and number of end-of-life care discussions; patient and surrogate attitudes toward having patients express preferences explicitly; factors most important to surrogates in decision making; and within-pair agreement about the values of suffering and certainty. RESULTS: Ninety percent of patients designated a family member as their surrogate. In most cases, having more conversations about end-of-life issues did not increase surrogate knowledge of patients' values or preferences. Surrogates wanted written and oral instructions more often than patients wanted to provide them (62% vs. 39%, p < 0.001). Knowing the patient's wish to stop treatment in the present condition was more important to most surrogates than the physician's recommendation to stop treatment (62% vs. 45%, p < 0.001). Compared to patients, surrogates were less likely to want to prolong the patient's life if it entailed suffering (12% vs. 23%, p < 0.01) and were more concerned about being certain before stopping life-sustaining treatments (85% vs. 77%, p < 0.02). CONCLUSIONS: Differences in preferences for the advance care planning process between patients and their surrogates and failure to discuss specific end-of-life values and preferences may explain why surrogates often lack information needed to serve as surrogate decision-makers.

New guideline describes nephrology community consensus on withholding and withdrawing dialysis. Recommendations regarding withdrawing dialysis. 2.

This article reviews two of the recommendations in the RPA/ASN clinical practice guideline that are particularly relevant to making decisions to stop dialysis. The final article in the series will review the recommendations in the RPA/ASN clinical practice guideline regarding resolving conflicts with patients and families and making decisions about whether to dialyze patients who are terminally ill from non-renal causes or who are unable to cooperate with the dialysis process. In all, the guideline makes nine recommendations regarding the treatment of patients with either acute renal failure or end-stage renal disease, and each recommendation is supported by a rationale. The guideline includes 25 prognostic tables and 302 references. The goal of the guideline was to improve patient care by promoting medically and ethically sound decisions about starting and stopping dialysis.

Recommendations regarding conflict resolution and forgoing dialysis in special patient populations.

The Institute of Medicine defines a clinical practice guideline as "a systematically developed statement to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." The goal of the RPA and ASN in developing this guideline was to help nephrologists and other members of the renal care team with challenging dialysis decisions regarding starting, continuing, and stopping dialysis.

A new clinical practice guideline on initiation and withdrawal of dialysis that makes explicit the role of palliative medicine.

More than 50,000 long-term dialysis patients die per year, with roughly 20% of these deaths after a decision to stop dialysis. After dialysis discontinuation, the average dialysis patient lives for only 8 to 12 days. The renal community recognizes and recommends a role for palliative care in the end-of-life treatment of these patients. This article describes the new clinical practice guideline developed by the renal community, Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, that makes explicit the role of palliative medicine in the treatment of dialysis-dependent patients who stop this treatment with the expectation that death will follow shortly.

Inappropriate use of dialysis for some elderly patients: nephrology nurses' perceptions and concerns.

The purpose of this study was to determine what percentage of elderly patients (age 65 years and older) nephrology nurses (NN) believe should not be dialyzed and to identify NN percep tions and concerns about the inappropriate use of dialysis for these patients. The design was descriptive using a cross-sectional survey instrument. Data was collected in 1996 from 393 NN (44% response rate), with a mean age of 41 years and 9 years of dialysis experience. The sample was 1,000 NN randomly selected from 7,000 members of the American Nephrology Nurses'Association (ANNA) who selected hemodialysis as a special area of interest. Quantitative analysis of respondents revealed that NN felt that 15% of elderly dialysis patients (EDP) should not be dialyzed, and 80% were troubled by decisions to start dialysis for some elderly patients. Content analysis of qualitative responses supported the NN concerns revealed in the quantitative analysis. Five themes with interrater reliability of > 98% were identified: qualiy of life (QoL), patient/family inadequate knowledge, patient influences on decision making age, and other (cost/legal reasons). QoL issues accounted for 75% of NN responses. Statistical analyses including an ANOVA, t-tests, and chi square failed to identify relationships between themes and demographic factors, such as age, gender, years of experience, education level, unit profit status, and type of staff position. The researchers conclude that NN believe dialysis is inappropriate for a significant percentage of EDP, these perceptions and concerns are widespread, and QoL issues are key factors in decisions to withhold or withdraw dialysis. NN may decrease the inappropriate use of dialysis by identifying QoL factors for EDP, facilitating discussions with family members and nephrologists, and continuing to advocate for the rights of EDP with poor QoL.

Concerns and self-reported competencies in end-of-life care: a survey of physicians in WV.

To assess concerns and self-reported competencies in end-of-life (EOL) care, we surveyed a random sample of West Virginia physicians and received 255 responses (33%). Those responding identified three major barriers to good EOL care: patient and family demands for all possible treatments, lack of physician education and inadequate financing. Most identified themselves as less than informed about EOL legislative and regulatory issues and were less than satisfied with their EOL symptom management skills. Most reported that their patients would want hospice care at the end of their lives, but indicated that a major reason for not referring a patient to hospice was patient and family denial of approaching death. Most respondents rated the overall quality of EOL care in West Virginia as fair to poor. We conclude that physician respondents recognize the need to improve their knowledge and skills in EOL care to improve the care of the dying in West Virginia.