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Discussion

when is enough, enough??

ive been a hd outpt RN for 7yrs. straight out of graduating and into dialysis. over the years ive learned so much and STILL feel that so much more can be learned.

but, the most memorable aspects of dialysis is being a witness to the misery that some pt's have to go through. seeing the same faces 3x a week, no matter how hard you try to maintain a professional boundary, these little guys somehow burrow themselves into your heart

but.. the big but... inevitably, as time passes and they get older, their minds and bodies begin to display the stress that comes not just from aging, but from dialysis too. the usual pattern ive experienced is that the patients who have dementia or are otherwise unable to make their own medical decisions are too often forced into coming to dialysis when they clearly DO NOT want to be there. yes, the dementia ones say 'im ok, im ok', but then when no one is looking, try to pull their needles out. or the ones who do have some visual recognition of where and who they are, are still wheeled in and placed in the tx chair when they are so obviously tired of it all and have said so to staff repeatedly, yet still agree to continue with dialysis for the day.

when im working with such pt's as mentioned above, I know that we-the clinic, cant force them to stay on dialysis, but why does the family allow it to happen? I know being a caregiver to a loved one is difficult, but don't they see what a toll it takes on them? it is hard to let them go... but how selfish can one be to see that they aren't happy? would you want to be living like that, day in, day out during your last miserable years of life?

there are families that just want the ssi check every month so they continue to bring them in, and there are families that are just SO co-dependant that, THEY don't know what would happen to THEM if the pt died! and then, this takes the cake, the family members that are given the POA and are too scared to make the decision for themselves to take them off of dialysis.

ive documented and spoken to the appropriate avenues allowed to the RN but I just feel this repeating too much. what do you think?

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    well, you answered your own questions. The family that continues dialysis because they are dependent on your patient for money or companionship, or lack of "what would I do without them?" It is hard. I've been doing it for 10 years now. I have seen elderly patients suffer on the machine because the family POA isn't ready to let go even when there is NO quality of life left for that poor family member. I had a sweet old lady who begged for years to take her off as soon as she was hooked up. She would sit there and holler and moan and cry out to God to please take her. We ended her treatment early when we could, the physician had talks with her daughter about end-of-life care, but daughter was just not ready to let go. It tortured everyone in the clinic, your neighbor patient doesn't want to hear all that carrying on. Our hearts broke for the sweet lady. Eventually she passed away from pneumonia. Very sad. In that case, I think the daughter was very well-off already, she didn't want to lose her mom.

    Other times, sadly enough, it is because the family relies on their check. This one man was blind, wheelchair-bound, demented. Access after access failed, femoral graft that started stealing from his toes, they became gangrenous. But the family kept on. The taxi driver told us that he was always sitting alone in a back room of the house when he came to get him every day. He died of sepsis in the hospital.

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    Largest growth in dialysis patients is in the > 70 age group.

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    • Experts

    Bring in your APRN to this mix. They can help to facilitate end of life discussions and reasons to cont or discontinue dialysis.

    I often start talking about palliative care when I see new pts. I also discuss with the pt and family realistic details of what a resuscitation entails. I also encourage pts and/or family members to obtain a HCPOA.

    So, bring in the APRN.

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