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View Full Version : Scottish nephrologists would choose home HD--for themselves



Dori Schatell
November 2, 2009, 05:21 PM
Hi y'all,

I'm looking at abstracts from the American Society of Nephrology meeting, and thought this one was interesting. Why do nephrologists insist on in-center HD for their patients, when virtually none of them would choose it for themselves?

[TH-PO400] Scottish Nephrologists' Dialysis Preferences: What We Would Choose and What We Offer

Siobhan K. McManus, Robert A. Mactier. Renal Unit, Western Infirmary, Glasgow, United Kingdom; Renal Unit, Glasgow Royal Infirmary, Glasgow, United Kingdom

In Scotland more than 95% of patients on hemodialysis attend for three times a week 4-5 hour hospital based dialysis. Their survival remains poor. The HEMO and ADEMEX trials did not suggest that increasing dialysis dose as measured by Kt/V improved survival. Evidence of better outcomes on home hemodialysis, long nocturnal hemodialysis and daily hemodialysis has been coloured by patient selection as randomised controlled trials (RCTs) have been difficult to perform. Pending the results of the Frequent Hemodialysis Network trials, we canvassed the opinions of Scottish nephrologists to see how their dialysis preferences correlated with the therapies we currently offer our patients.
We emailed a web-based questionnaire to consultant and career nephrologists in Scottish renal units asking: If you were to find yourself with end stage renal failure in need of renal replacement therapy with no prospect of a renal transplant which of the following dialysis options would you prefer? Options included hemodialysis or hemodiafiltration (HDF) of varying frequency and duration, peritoneal dialysis and conservative management with treatment at home or in-centre. Responses were anonymous but gave information on the types of dialysis their units offered.
Of 92 nephrologists contacted, 70 completed the survey (76% response rate). 60% were consultants. 16% chose peritoneal dialysis. Only one nephrologist chose in centre hemodialysis but at a time and location of their choosing which is not an offer currently afforded to many Scottish patients. 83% chose daily and/or long duration hemodialysis or HDF which are not generally available to our patients. Equal numbers chose hemodialysis and HDF. 94% chose a home based treatment. There was no correlation between units with home hemodialysis programmes or HDF and the frequency of these choices. There was no significant difference between the choices of consultants and trainees.
In spite of the lack of RCT evidence, more than 80% of nephrologists chose long nocturnal and/or daily hemodialysis which are treatments we do not offer most Scottish patients.

MiracleMan
November 3, 2009, 04:59 PM
Interesting that 1 select in-center. Wonder what his reasonings were for his decision and why it would be of his choosing.
Also interesting that many chose long duration but yet many do not offer this to their patients as of yet. Seem like they are shooting for the best if it was them, but when it comes down to the patients, many do not have the luxury to chose.

Great Article

//MM

Dori Schatell
November 3, 2009, 07:27 PM
I know, right? Kinda makes me want to write an article about hypocrisy among doctors. <Sigh>

NDXUFan12
November 19, 2009, 04:06 PM
Interesting that 1 select in-center. Wonder what his reasonings were for his decision and why it would be of his choosing.
Also interesting that many chose long duration but yet many do not offer this to their patients as of yet. Seem like they are shooting for the best if it was them, but when it comes down to the patients, many do not have the luxury to chose.

Great Article

//MM


Oh, where, oh where, have we heard that before? The motto of the dialysis industry, "Do as I say, not as I do."

Mark

Beth Witten MSW ACSW
November 19, 2009, 07:22 PM
Could it have anything to do with:
-- Knowing and valuing their lifestyle more than they know and value their patients' lifestyles;
-- Underestimating patients' ability to perform dialysis safely and their motivation to do dialysis as often or as long as prescribed;
-- Over-estimating the control they have over patients when they only see them in clinic a few hours a week and when patients must manage their health a total of 168 hours a week with or without supervision (and appropriate knowledge to do so);
-- Under-estimating how important it is for patients to have control and understand what they need to do and why they should do it to achieve a level of functioning that will allow them to do those things they need and want to do

Jane
November 20, 2009, 08:59 AM
Beth,
Ppl are who they are when they come to dialysis. If they were not studious and self-disciplined when they arrived, they do not suddenly change. Wonder if you have witnessed success stories of patients who do change and learn to be responsible for their care, thus do well on dialysis? I have always thought it is appalling the way nephs/nurses look down upon dialysis patients, speak abusively to them and make them the butt of their jokes. They have bully behaviors since patients are tied up to a machine and can;'t defend themselves. The disrespect is unreal and has no age barriers. Whether patients are more together or lost souls, without some sort of intervention they are not going to achieve mastery over their txs. Just wondering what your experience has been?

Dori Schatell
November 20, 2009, 11:57 AM
Outpatient institutionalization--that's what in-center HD is, IMHO. I've heard the stories for years about people in clinics being yelled out, threatened, one time someone with a broken foot actually had a nurse purposely kick him in the foot! Power over someone else can be a very dangerous thing, and when a group of folks can't get out of their chairs, they are very vulnerable if the folks caring for them don't have their best interests at heart. There are lots of fabulous people working in dialysis who really care, but like any other profession, there are also some who don't belong.

I am familiar with folks who've gone from passive in-center to home, but it would be a lot easier if we'd start folks out with the expectation that they CAN go home (or at least do in-center nocturnal)--and should if they want the best treatment and the best life.

NDXUFan12
November 29, 2009, 05:04 AM
Absolute power corrupts absolutely. The first time that any dialysis center employee did any of those things to me, they would be picked up three feet off the ground and put on a coat hook, have a nice life. The arrogance of these people is amazing. Nephs/Nurses think that dialysis patients are stupid. Well, when they run around acting like control freaks, they look like fools to us. More than a few times, I have given the clinic staff/Lab/Nx Stage an earful when they wanted me to pay for their laziness or stupidity. The only real reason that the dialysis center staff abuses the patients, is because the patients tolerate it, pure and simple. Realize that eventually, they have to take the patient off of the machine and then, sock it to them. You might want to bring some of your bully dialysis staff members to me, I guarantee the patient will not be abused again. I could care less what they think. If a staff member hits a patient, the patient needs to press charges for assault and battery, staff member goes to jail, what a crying shame. I know they will not kick the police officer, assaulting a police officer is a felony.

Mark

NDXUFan12
November 29, 2009, 05:07 AM
Outpatient institutionalization--that's what in-center HD is, IMHO. I've heard the stories for years about people in clinics being yelled out, threatened, one time someone with a broken foot actually had a nurse purposely kick him in the foot! Power over someone else can be a very dangerous thing, and when a group of folks can't get out of their chairs, they are very vulnerable if the folks caring for them don't have their best interests at heart. There are lots of fabulous people working in dialysis who really care, but like any other profession, there are also some who don't belong.

I am familiar with folks who've gone from passive in-center to home, but it would be a lot easier if we'd start folks out with the expectation that they CAN go home (or at least do in-center nocturnal)--and should if they want the best treatment and the best life.


The nurse deserves to be jailed for assault, three members of my family are Registered Nurses. Power is a dangerous thing, I wonder who has said that time and again on these boards, anyone have any ideas?