Dialysis, HIV and terminal Pts. Abuse? - page 3

i am having extremely mixed emotions about dialysis use/abuse, especially with the increase in the numbers of elderly and substance abuse hiv patients going on dialysis. i always worry how sterilized the dialysis equipment is... Read More

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    I understand what the OP is saying and I think some people are misunderstanding the post. Some people hit it right on the mark. I don't think she is talking about taking a decision away from the patient or their family. She is saying that maybe dialysis should not be offered to everyone and there comes a point were doctors should be having palliative care discussions with families and patients instead of just doing everything possible to keep them alive. Palliative care is often underused. With some patients, we should be concentrating on reducing the severity of their disease symptoms rather than working to stop, delay or reverse the progression ot the disease. We should instead be trying to improve the quality of life. Working in a MICU, I see dialysis offered far too often and quickly. If every organ has failed and now the kidneys follow, I don't think we should offer dialysis. We will at this point not cure the patient or make their lives better by offering dialysis. I think dialysis should be used as a bridge, a means to an end and just not a means for keeping people alive with no end.
    Would you offer a VAD or artificial heart to everyone in heart failure who fails medical intervention? I think most people would say no. However, dialysis is the same issue. A VAD is
    an artificial machine that acts like the failed ventricle. Dialysis is an artificial machine that acts like a failed nephron. So, they are both artificial means of keeping people alive.
    The US uses dialysis more than an other country. I think this is partially because it is paid for through Medicare. It is also in part because of our health care system being driven by the consumer. But, I think it is mostly due to the beliefs and cultures in the US. We as a culture will take life regardless of quality over life dependent on quality.
    Last edit by questionsforall on Aug 21, '10 : Reason: addition

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    Missj, this is a debate which comes up in any discussion on Nursing Ethics; given an inexhaustible supply of tax funds-which health care providers would love to have, but which we all know is a pipe dream-then sure, no problem, plenty of resources=care for everyone, regardless of their bad habits. But the sad fact is, resources are limited, so it becomes a question of, "who do we give priority to?" We can not put an unreformed alcoholic on the list for a liver transplant, now can we? You don't advocate that, do you? And if patients go into kidney failure from indulging their yen for dangerous and illegal substances, would you force non-abusers to stand in line so you can treat addicts first?

    I don't know how American medical insurances work, but in South Africa, many medical aids, except the most expensive plans, will not cover treatments for diseases arising out of alcohol or drug abuse-they are regarded as "self-inflicted", and many will not pay for rehab either (which I think is too harsh). I don't know if the news reports concerning our former (now late) Minister of Health ever reached America, but in 2007 she was admitted to a private hospital for a liver transplant. It caused a hell of a stink here, because she was well known to be a heavy drinker, and in fact ordered herself a bottle of red wine while she was still recovering! She died last December, from "complications relating to the transplant"... Think it was right, or fair, to allocate an organ to someone who simply was not going to look after it?

    As for HIV, I fully support free ARV programs, but I have little patience with defaulters. Where TB is concerned, I have no patience. At least be responsible enough to continue with your treatments, other peoples' lives are at risk!

    When it comes to extending the lives of loved ones, when they are unable to decide for themselves, I would hope that families' decisions are made in the light of wisdom and humaneness. I think it happens too often that relatives insist on interventions that are not only going to be unsuccessful but are going to cause considerable pain, suffering and loss of dignity to their beloved mothers/spouses etc. Sometimes it is better to let go.
    morte and Hospice Nurse LPN like this.
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    There is a difference between dialysis and transplants. If there were people standing in line waiting for dialysis and unable to get it because of abusers, it obviously makes sense to have a criteria of the perosn who most likely gets the benefit of it, but to be honest, there are times when the transplant issue really breaks my heart as well...and I wish we had enough to go around so even those who you dont feel "deserves it" would have that opportunity. A very beautiful and sweet patient that I grew to know very well at our clinic died a few weeks ago because she did not get a transplant before her body shut down. She had a history of alcohol abuse, but that didnt stop me from crying at her loss, and wishing there were a way we could have saved her, feeling the world were less for her not being in it.

    Perhaps seeing drug addicts, HIV patients, alcoholics, and psychiatrically challenged patients every day, the same ones repeatedly, and watching them struggle with those, growing to love many of them in my own way, makes it hard for me to understand the idea that they are an acceptable loss. They are people, they live, breathe, love and smile just like everyone else, and they have every right to it.

    Back to the original issue though... if dialysis is not a way to 'bridge' towards better health, if it will just prolong the inevitable, maybe that should be ok too. More time to say good bye is still more time. I dont even Kevorkian would deny a patient that, if that was their choice...
    DizzyLizzyNurse likes this.
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    Quote from missjennmb
    There is a difference between dialysis and transplants. If there were people standing in line waiting for dialysis and unable to get it because of abusers, it obviously makes sense to have a criteria of the perosn who most likely gets the benefit of it, but to be honest, there are times when the transplant issue really breaks my heart as well...and I wish we had enough to go around so even those who you dont feel "deserves it" would have that opportunity. A very beautiful and sweet patient that I grew to know very well at our clinic died a few weeks ago because she did not get a transplant before her body shut down. She had a history of alcohol abuse, but that didnt stop me from crying at her loss, and wishing there were a way we could have saved her, feeling the world were less for her not being in it.

    Perhaps seeing drug addicts, HIV patients, alcoholics, and psychiatrically challenged patients every day, the same ones repeatedly, and watching them struggle with those, growing to love many of them in my own way, makes it hard for me to understand the idea that they are an acceptable loss. They are people, they live, breathe, love and smile just like everyone else, and they have every right to it.

    Back to the original issue though... if dialysis is not a way to 'bridge' towards better health, if it will just prolong the inevitable, maybe that should be ok too. More time to say good bye is still more time. I dont even Kevorkian would deny a patient that, if that was their choice...
    You are a good, caring nurse, and I respect you for it. If there was a way to force the powers that be to stop misallocating/misappropriating/mismanaging the obscene amounts of money that would be better utilized in essential services, we probably would be able to treat everyone, regardless of their background. Sadly, until nurses take over the world, that is not going to happen, and we are forced to prioritize, and we can't allow ourselves to trip over our emotions.

    "Each man's death diminishes me, for I am a part of Mankind". That line came up in my mind when I read your post, and it is a wonderful principle to live by; however, do not allow yourself to be diminished-you need to be a whole person in order to care for your remaining patients, and in fact to be able to function at all!


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