Quality of life of individuals with end stage renal disease: perceptions of patients, nurses, and physicians.

OBJECTIVE: The objectives of this study were to describe the perceptions of physicians, nurses, and patients regarding the quality of life (QOL) of individuals with end stage renal disease (ESRD), to identify differences in ratings of QOL, and to identify predictors of perceptions of QOL for each group. DESIGN: A cross-sectional, descriptive comparative design was used. Three measures of QOL, the Self-Anchoring Striving Scale, Index of Well-Being, and Time Trade-Off were used. SAMPLE/SETTING: The subjects included 215 patients with ESRD (including dialysis and transplant), and 42 nurses and 7 physicians who cared for them. All were from a major tertiary care hospital renal program in western Canada. METHODS: Patients were interviewed and asked to complete questionnaires relating to quality of life, health status, functional status, outlook, support, medical, and demographic characteristics. Three measures of QOL, the Self-Anchoring Striving Scale, Index of Well-Being, and the Time Trade-Off were used. Primary physicians and nurses were asked to complete the same questionnaires within one week of the patients. RESULTS: It was found that there were significant differences in the ratings among the groups. The nurses' ratings of patients' QOL were significantly lower than were patients (T2 = 21.89, df = 5, 377, p < .001). Physicians' mean ratings were higher than patients' ratings (T2 = 14.24, df = 5, 338, p < .05). Correlations among patients', nurses', and physicians' ratings of QOL ranged between .19 and .49. It was also found that different variables explained the perceptions of each group regarding the patients' QOL. CONCLUSIONS: In this study, nurses, physicians, and patients rated the QOL of individual patients differently, and different factors explained the perceptions of QOL of each group. Although findings of the study are not generalizable, it may be advisable for nurses to be aware that patients and physicians may not share their perceptions of patients' QOL.

Economic, social, racial and age-related considerations in dialysis and transplantation.

Economic, social, racial and age-related considerations in dialysis and transplantation beg the question: how successful are different countries in addressing the problem of distribution of scarce resources, in making 'tragic choices' on who gets treated when not everyone can get what they need? They broach the issues of distributive justice. Whereas the literature mainly addresses these questions in the developed Western world, this review also includes issues that involve the developing world.

Attitudes of dialysis patients and caregivers regarding advance directives.

OBJECTIVE: The objective of this study was to describe and compare the attitudes of dialysis patients, their relatives/friends, primary nephrologists, and nurses regarding advance directives. DESIGN: A descriptive comparative design was used. SAMPLE/SETTING: A total of 50 dialysis patients from a large teaching hospital in western Canada participated in the study. For every patient who responded, a relative/friend, physician, and nurse completed the questionnaire. METHODS: The questionnaires were designed for the purposes of the study. These questionnaires were mailed to dialysis patients, who were asked to identify a relative/friend to complete a similar questionnaire. Nurses and physicians also completed questionnaires. RESULTS: Overall, 84% of patients indicated that they believed that it was important to leave a living will, but only 18% of these patients had actually left an advance directive. However, 52% of patients and relatives/friends believed that major treatment decisions should be left to the physician, a perception that was not shared by physicians and nurses. CONCLUSIONS: It appears that patients, family/friends, nurses, and physicians in this study had differing perceptions regarding advance directives. It is important that health care professionals realize that these differences may exist and that further research should address strategies to increase our understanding of patient decisions in this area.

Ethics in organ donation: contrasts in two cultures.

1. For cadaveric organs in the West, there are many avenues that should be pursued in order to increase the supply. Most of the measures under "giving" in Table 2 are ethical, though we do not accept the implication that those who enroll, in advance, as future organ donors should thereby obtain priority for their own possible future transplant organ needs. 2. "Legislated taking" could be ethically justified if shown to be acceptable to most persons in a society or culture, with provision for opting out for those with minority opinions and beliefs. Such evidence should be sought, and acted upon if found to be present. It certainly warrants a strong public education thrust. 3. Possibilities should be explored for nonmonetary rewarding of families of the decreased, in ways that would not foreclose on families giving authorization for purely altruistic reasons. Direct money payments, "buying," will never outweigh the ethical arguments against the practice, in our opinion. There are other societal avenues by which to pursue the perfectly acceptable goals of indirect altruism. 4. For kidney donations from unrelated living donors in India, a case is made for considering rewarded gifting as being ethically acceptable if it is defined in the way that it is carefully defined for this article, provided it meets the criteria for indirect altruism of a panel of social peers, and also is linked to measures of mandated philanthropy (decided also by a panel of social peers), for the reasons given. This is a balance of societal burden (in allowing rewarded gifting) by the ensured benefit to the seller (to prevent his victimization) plus a required benefit to society by seller's philanthropy. The setting of these balances should be decided by a panel of social peers. Such acceptance would not necessarily pass muster for other cultures than the one for which it is designed. 5. All forms of commerce, included that described in the preceding paragraph, become ethically unacceptable if the regulations governing them cannot realistically be enforced. This is a crucial point, a requirement for ethical cogency.

Immunoglobulin allotypes in several North American Eskimo populations.

Genetic data consisting of immunoglobulin testing (GM and KM) from 631 Eskimos from 5 populations are reported. These populations are Savoonga, Gambell (St. Lawrence Island), Wales, King Island, and Mckenzie Delta, Baffin Island. The GM and KM haplotypes are analyzed and compared to those occurring in Greenland, Canadian, Alaskan, and Siberian Eskimos and to other Siberian indigenous populations. These analyses suggest that during the peopling of the New World, four separate migrant groups crossed Beringia at various times.

Kidney stones and lithotripters: critical analysis of the introduction of extracorporeal shock wave lithotripsy into Canada.

It is possible for a nonpharmaceutical medical innovation to enter the mainstream of the health care system without its efficacy and effectiveness having first been established by means of a randomized controlled trial (RCT). The result of this omission may be the discreditation and abandonment of the technology or procedure but not before precious resources that could have been better used elsewhere in the health care system are absorbed. A possible example of such a misallocation of resources is the introduction into Canada of extracorporeal shock wave lithotripsy (ESWL) for the treatment of urolithiasis. We review the development and diffusion of ESWL and recommend ways in which the deficiencies in regulating the introduction of new medical technologies can be corrected.

An alternative approach for statistical analysis of kidney transplant data: multivariate analysis of single-center experience.

To avoid the center effect and the possible hidden interactions of multicenter studies, the validity of the Cox Proportional Hazards Model for the analysis of a single-center kidney transplant program was tested, considering 287 renal transplants performed in a 10-year period. The inclusion of type of donor and main immunosuppressive drug as covariates in the model did not violate the proportionality assumption of the Cox model. According to this method, the following covariates were significant in predicting graft survival: cyclosporine, type of donor, good human leukocyte antigen (HLA)-A and HLA-B match (DR data were not considered), highest percentage of reactive antibodies against panel cells, and nephroangiosclerosis as a primary renal disease. Cyclosporine did not significantly improve graft survival in living related donor transplants. Pretransplant blood transfusions, cold ischemia time, and donor ABO blood group were initially significant but dropped out in the step-down procedure. Recipient's age at transplant, cyclosporine, HLA-A and HLA-B match, and nephroangiosclerosis were significant in predicting patient survival. It was concluded that using long-term data of cadaveric and living related renal transplants either on azathioprine or cyclosporine is a valid way to perform multivariate analysis of single-center transplant programs that do not have large samples.