Advance care planning: The patient perspective.

Advance directives ensure that an individual's wishes for health care are honored. Only about one-half of dialysis patients have advance directives, and less than 10% of patients have had discussions about end-of-life care with their physicians. The Coalition for Supportive Care of Kidney Patients interviewed patients regarding their experience completing advance directives. Themes identified included a precipitating health care crisis, the experience of decision-making for others, and availability of advance directive information. Patients offered recommendations and best practices for increasing advance directives completion. The Coalition also identified resources to assist with completion of advance directives.

An interdisciplinary approach to dialysis decision-making in the CKD patient with depression.

Depression and depressive symptoms are common in advanced kidney disease and are associated with poor outcomes. For those with CKD not on dialysis, depression may influence how patients cope and prepare for their disease and its management, including decisions about dialysis treatment. Patient self-reported scales exist to better identify depression; how to incorporate these scales into clinical practice and assist with treatment decision-making is less clear. We present a case-based discussion of depressive symptoms in patients with advanced kidney disease not on dialysis. We highlight the contribution of underlying somatic and psychosocial factors in the assessment and management of depression. We further define the role of the interdisciplinary care team, including palliative care and hospice medicine, to assist with symptom management and end-of-life care for CKD patients with depression.

The demented patient who declines to be dialyzed and the unhappy armed police officer son: what should be done?

Dialysis personnel are responsible for ensuring that patients' rights and physical safety are protected in dialysis centers. Treatment of patients with cognitive impairment, including patients with dementia, presents special challenges. These patients may attempt to pull out their dialysis needles during treatment, potentially endangering themselves, dialysis center personnel, and other patients. Such patients may also compromise the care of other patients in the center by upsetting them and requiring a disproportionate amount of staff attention during treatment. Dialysis centers have learned to require families of such patients to provide a sitter to ensure that the patient remains safe during the dialysis treatment; however, some patients may exhibit unsafe behaviors despite a sitter, and not all families are willing to provide a sitter. In some instances, family members respond to the stress of a loved one who is unsafe on dialysis by being verbally or physically abusive to dialysis staff. This article presents a case in which the family member was a police officer who was not only verbally and physically intimidating to the staff but also insisted on bringing his police service weapon into the dialysis center. It describes the psychosocial, ethical, and legal responses to a family member who is disrupting what should be a calm environment in the dialysis center and recommends that dialysis centers proactively develop policies concerning safety for patients, family members, and other visitors that make no exceptions. The case also highlights the importance of adopting a no weapons policy and posting and enforcing a no weapons sign.

Hospice and ESRD: knowledge deficits and underutilization of program benefits.

Although hospice care for dying patients on dialysis has been recommended in clinical practice guidelines and policy statements of professional nephrology organizations, only a minority of dying patients on dialysis currently receive hospice services. This retrospective qualitative study investigated a variety of factors contributing to the low referral rate for patients with end stage renal disease (ESRD). Interviews (N=338) were conducted with dialysis facility professionals (RN staff nurses, social workers, nurse managers) in ESRD networks 1, 5, and 12 using a standardized telephone survey. The sample (N=448) consisted of patients who discontinued dialysis and died between September 2005 and February 2006. The study illuminated a striking variation by discipline in the understanding of Medicare ESRD benefits and Medicare hospice benefits as they apply to patients with ESRD. Social workers were more knowledgeable that patients on dialysis were eligible for the Medicare hospice benefit while continuing dialysis with a non-kidney-related terminal diagnosis than RN staff nurses or nurse managers (79% of social workers, 64% of nurse managers, and 48% of RN staff nurses were knowledgeable [p < 0.001]). Nurses were significantly more likely than social workers to be uncertain about the process of hospice referral (28% of nurse managers, 17% of RN staf nurses, and 9% of social workers [p < 0.001]). Additionally, the study found that depending on geographic region, hospice programs varied in accepting patients who wish to continue dialysis treatment. This study identified multiple barriers to referral to hospice care ofpatients with ESRD who are dying. It illustrates that hospice organizations, dialysis facilities, and dialysis unit nurses need education regarding the eligibility for Medicare hospice benefits in conjunction with a patient receiving the Medicare ESRD benefit.