Time to Improve Informed Consent for Dialysis: An International Perspective.

The literature reveals that current nephrology practice in obtaining informed consent for dialysis falls short of ethical and legal requirements. Meeting these requirements represents a significant challenge, especially because the benefits and risks of dialysis have shifted significantly with the growing number of older, comorbid patients. The importance of informed consent for dialysis is heightened by several concerns, including: (1) the proportion of predialysis patients and patients on dialysis who lack capacity in decision making and (2) whether older, comorbid, and frail patients understand their poor prognosis and the full implications to their independence and functional status of being on dialysis. This article outlines the ethical and legal requirements for a valid informed consent to dialysis: (1) the patient was competent, (2) the consent was made voluntarily, and (3) the patient was given sufficient information in an understandable manner to make the decision. It then considers the application of these requirements to practice across different countries. In the process of informed consent, the law requires a discussion by the physician of the material risks associated with dialysis and alternative options. We argue that, legally and ethically, this discussion should include both the anticipated trajectory of the illness and the effect on the life of the patient with particular regard to the outcomes most important to the individual. In addition, a discussion should occur about the option of a conservative, nondialysis pathway. These requirements ensure that the ethical principle of respect for patient autonomy is honored in the context of dialysis. Nephrologists need to be open to, comfortable with, and skillful in communicating this information. From these clear, open, ethically, and legally valid consent discussions, a significant dividend will hopefully flow for patients, families, and nephrologists alike.

Improving nephrology service delivery - Accessing the specialist.

BACKGROUND: The increased prevalence of chronic kidney disease (CKD) is straining the medical workforce and healthcare budget. To improve efficiency, patients require streamlined access to renal and general practice specialist advice. OBJECTIVE: The aim of this article is to profile general practitioner (GP) referrals for patients with CKD and compare these referrals to national guidelines. METHODS: We conducted a retrospective analysis of 200 randomly selected outpatient referrals to the renal service at St George Hospital, Sydney, between 2008 and 2011. These referrals were compared against national referral guidelines. RESULTS: Declining renal function accounted for the majority (44%; n = 78) of referrals, while advice regarding hypertension management contributed to a further 21% (n = 38) of referrals. Fifteen per cent (n = 27) of patients were referred back to their GP after one visit, while 40% (n = 72) required follow-up beyond 12 months. When compared with the National nephrology referral guidelines, 25% (n = 42) of referrals did not meet the criteria. DISCUSSION: Access to renal specialists may be difficult because of bottlenecks in the public clinic, frustrating all parties concerned. If an alternative, more integrated, possibly web-based CKD support service existed, some formal reviews could be bypassed. This study provides preliminary data supporting the development of such a service, and simultaneously providing streamlined sup-port to the GP and relieving pressure on hospital clinics.

NURSES' BEREAVEMENT NEEDS AND ATTITUDES TOWARDS PATIENT DEATH: A QUALITATIVE DESCRIPTIVE STUDY OF NURSES IN A DIALYSIS UNIT.

BACKGROUND: Dialysis nurses have a unique relationship with their patients and often require bereavement support should a patient death occur. This study was conducted in 2014 and aimed to explore the attitudes of dialysis nurses to death and dying and to identify suitable bereavement strategies following a death of a patient. METHODS: A purposeful, convenience sample of all nurses employed in the dialysis service completed a demographic profile and The Death Attitudes Profile Revisited (DAP_R) survey. RESULTS: There were 52 responses to the survey (98% response rate). The mean age of the participants was 45 years ± 8.0 years; 87% had >10 years nursing experience. Nurses suggest that debriefing and the use of a counsellor would support them in their grieving process while new graduate nurses appear to require extra support following a patient death. Analysis of the death attitude profile-revised (DAP-R) showed significant relationships between fear of death/death avoidance as well as fear of death/neutral acceptance. Spirituality and religion correlate strongly with 'Approach Acceptance' in this study group. Forty-four percent people who 'approach acceptance' of death can be explained by the strength of religious beliefs. CONCLUSIONS: Many dialysis nurses appear to have strong religious or spiritual belief systems and this contributes to their acceptance of death, although there also appears to be a degree of death avoidance. The study has highlighted the need to provide adequate bereavement support for dialysis nurses.