Dialysis Compliance Buy-In...

  1. 7

    Noncompliance for chronic hemodialysis patients is multi-factorial. Improving compliance is the responsibility of everyone but the end result, either positive or negative lies with the patient. As providers, we owe it to our patients to work with them as to reasons and reasonable solutions.

    Why are chronic hemodialysis patient noncompliant? This is the $64,000 question. With Medicare demanding more and more from providers, we must get creative in ways to encourage our chronic hemodialysis patients. First, we need to explore why our patients ARENíT compliant:

    * Could it be coming to an outpatient dialysis unit takes too much time?
    * Do they have transportation issues?
    * Is childcare an issue?
    * Have they been on dialysis for many years, not eligible for transplant and see no future?

    Chronic outpatient hemodialysis in the US is typically three times per week for four hour sessions. It can range from 3 hours to as long as 5+ hours as it is roughly based on your body mass. So, it does take time. Can we give the patient some choice in times? Perhaps they are a morning person, want to come in at 5:30am, do their treatment and get one with their day. They may work during the day and want to come in the evening and then go home and sleep. Nursing home patients are typically scheduled during the middle of the day due to transportation arrangements.

    Speaking of transportation, do the patients have reliable transportation? What options are there for public transportation, perhaps a cab would be an option. In Illinois, for instance, where I live, Medicaid funds cab rides to and from medical appointments for some of the patients. Can a carpool be arranged? If there primary means of coming to dialysis isnít available, what alternatives are in place?

    Many newly diagnosed end stage renal disease patients are young with young children at home. Do they have reliable daycare? Is it affordable? Are they feeling up to caring for children after dialysis? Is there another caregiver for the children? And...finally, are they hopeless? Does the patient feel as though there are no alternatives except outpatient hemodialysis? Have the options including peritoneal (PD) , nocturnal hemodialysis (if available in your area), home hemodialysis been explained fully to the patient.

    Lots of questions, not a lot of answers. However, we can start to get answers by asking patients, whatís up? We missed you last time, is there something we can do to help you best care for yourself? It all comes down to buy-in - the patient needs to feel they have some control and are in the driverís seat. Sadly sometimes the only way they can demonstrate this is to be noncompliant.
    Last edit by traumaRUs on Aug 16, '12
    sharpeimom, CrufflerJJ, nurse671, and 4 others like this.

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    About traumaRUs, MSN, APRN, CNS

    traumaRUs has '20+' year(s) of experience and specializes in 'Nephrology, ER, ICU'. From 'Midwest'; Joined Apr '00; Posts: 42,266; Likes: 17,309.

    Read more articles from traumaRUs

    13 Comments so far...

  3. 1
    Don't have much to add in terms of compliance, but I really feel for these patients. I can't see any quality of life in being chained to a dialysis chair for six hours three times a week. What a miserable life and miserable existence. If it were me, I would opt for no dialysis and just let nature take its course. JMHO, of course.
    SHGR likes this.
  4. 3
    Always a rough decision Vicky. For younger pts or those with a chance at transplant, its worth it to bridge with dialysis to transplant. Many of my pts work full time. Not everyone feels awful on dialysis. One of my very good friends, not pt, worked full time as an RN for 5 years while doing hemodialysis until she got a transplant. A very awesome person!
    SHGR, nurse671, and VickyRN like this.
  5. 1
    Vicky, I have often thought the same thing. TraumaRus, thanks for a great article. I do feel for our population with kidney failure. Prevention is so important!!
    traumaRUs likes this.
  6. 2
    I am a renal nurse in the UK and also a key worker for teenagers with renal disease. Non compliance with hemodialysis is complex, and seems to me to be partly due to control issues. They have no control over dialysis, they have to attend or they die. This produces a great deal of resentment and frustration. Often not attending dialysis is a way to try and gain some control. In the UK, we are trialing a Shared Care initiative, encouraging patients to take a more active role in their treatment by programming the machine etc, I am not sure if you already have this in the US but initial results are encouraging.
    Quote from traumaRUs
    Why are chronic hemodialysis patient noncompliant? This is the $64,000 question. With Medicare demanding more and more from providers, we must get creative in ways to encourage our chronic hemodialysis patients. First, we need to explore why our patients ARENíT compliant: * Could it be coming to an outpatient dialysis unit takes too much time? * Do they have transportation issues? * Is childcare an issue? * Have they been on dialysis for many years, not eligible for transplant and see no future?Chronic outpatient hemodialysis in the US is typically three times per week for four hour sessions. It can range from 3 hours to as long as 5+ hours as it is roughly based on your body mass. So, it does take time. Can we give the patient some choice in times? Perhaps they are a morning person, want to come in at 5:30am, do their treatment and get one with their day. They may work during the day and want to come in the evening and then go home and sleep. Nursing home patients are typically scheduled during the middle of the day due to transportation arrangements. Speaking of transportation, do the patients have reliable transportation? What options are there for public transportation, perhaps a cab would be an option. In Illinois, for instance, where I live, Medicaid funds cab rides to and from medical appointments for some of the patients. Can a carpool be arranged? If there primary means of coming to dialysis isnít available, what alternatives are in place? Many newly diagnosed end stage renal disease patients are young with young children at home. Do they have reliable daycare? Is it affordable? Are they feeling up to caring for children after dialysis? Is there another caregiver for the children? And...finally, are they hopeless? Does the patient feel as though there are no alternatives except outpatient hemodialysis? Have the options including peritoneal (PD) , nocturnal hemodialysis (if available in your area), home hemodialysis been explained fully to the patient. Lots of questions, not a lot of answers. However, we can start to get answers by asking patients, whatís up? We missed you last time, is there something we can do to help you best care for yourself? It all comes down to buy-in - the patient needs to feel they have some control and are in the driverís seat. Sadly sometimes the only way they can demonstrate this is to be noncompliant.
    madwife2002 and traumaRUs like this.
  7. 0
    Totally agree with you - seems like teens are the hardest to get to "buy-in" to dialysis, need for meds, etc..
  8. 2
    I have only a moment here (great article/posting btw.)

    We know (by data and the experiential) that many dialysis patients end up on dialysis because they were not good life-managers to begin with.

    While there is great value in pursuing every opportunity available for ESRD patients to succeed on dialysis, I know there has been recent increased interest in studying prevention methods amongst the most vulnerable to failure.

    While it's great we provide programs (such as transportation arrangements) to facilitate compliance and adherence to treatment...it can become a bit like closing the barn door after the horses are out.
    SHGR and traumaRUs like this.
  9. 3
    Agree Guttercat. We need to prevent ESRD by dealing with the HTN and DM that brings the majority of CKD pts to ESRD and dialysis.
  10. 0
    Prevention is something which I am passionate about, especially in the inner-city where poverty prevails, education is poor and lifestyles mean you cannot always afford to go and see your doctor.

    The other passion of mine is the funding of anti-rejection medications which stops being paid for by Medicare 3 years post transplant, causing failure when they can no longer afford the $1000 per month medications!
    So then we are on the vicious circle of going back on dialysis, which costs more than $1000 per month.

    I understand that once a pt is transplanted the expectation is that the patient is now well! So they should find a job!
    Unfortunately this is not as simple or easy as it sounds for patients, plus how many pts have transplants and although they dont need dialysis have multiple problems with their transplant.
  11. 1
    Dialysis compliance is really hard, because the majority of patients got to ESRD by being non-compliant. I've basically learnt to accept that my long-term patients have heard it all before and let them make their own decisions, even if that is not in their own best interests.

    Fortunately, I work in Australia, so our patients have access to affordable healthcare and many social programs that facilitate dialysis attendance, including transport and welfare. We do our best to work the patient roster to times that suit them, especially those that work. Unfortunately, you can do all these things, but for some people, their health is not a priority and that is their decision.
    madwife2002 likes this.


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