Home dialysis candidate?

My father in law has long had chronic kidney disease. He has been stage 5 for quite some time, and his GFR is between 8 and 10.
He claims to feel fine. He has decided to try home hemodialysis when the time comes.
He and my mother in law are in their late 70s and struggle with new technology, so I am concerned about their ability to learn to
do this. I am an RN, and it looks like quite a steep learning curve to me.

Also, he called our local transplant coordinator with thoughts of going active on the transplant list again and she discouraged him
and talked him out of it since he is still feeling well.

Any thoughts? I live in Michigan, USA.

A good question … and one where, though I can offer no specific comment, I can make some general observations.

First, I strongly believe - and our long experience reaffirms - that age is not a barrier to successful home dialysis. We have a number of patients 75 and older (and a couple of patients past 80 - one of whom who has lone-dialysed for nearly 9 years now) who successfully manage self-haemodialysis (nocturnal) at home.

Age is in the eye of the beholder. Take me … though into the second half of my 60’s, I feel, and (hopefully) still approach my life as a young(er) man. OK, things creak a bit. Sooner or later my pace must (and will) slow. But … that doesn’t mean that I have to become dependent on others! And … I would hope, long live that view.

Our older patients are slower. But - that can be an advantage. Yes, they may train a bit slower. They may need a magnifier (we use a low-cost, back-lit magnifier on a stand … there are heaps on the market) to assist with self-needling. They shouldn’t be rushed. We train older patients at their pace, not ours - though they may need a bit of a ‘push’ now and then to get them over ‘humps’ in the training road! Indeed, our experience is that older patients have more time. Though slower, they are often more thorough. They are less likely to cut corners in training, or, more importantly, less likely to ‘adapt’ their training once they get home to less ideal (and sometimes reckless) speed-related errors in technique. In short, we like older home haemodialysis patients.

So, it can be the mindset of the family that needs more change than the mindset of the patient. You say he feels fine. I would have no hesitation in believing this to be so. Older people often ‘wear’ a low eGFR’s far more easily that younger patients. We have had many patients whose eGFR, way under 10, has seemed not to ‘rock their boat’.

Why? Why is it that some wilt and fade at eGFRs of 11, 12, 13 … while others are perky and bright, swearing no ill health at an eGFR of 7 or 8? Well … I wish I knew the answer to that … I’d bottle their elixir! … but, it is so.

So, your F-i-L is not unusual. Just lucky, I guess. While there are some reasons why older patients can tolerate a lower eGFR … dwindling muscle mass, changes in metabolic rate, a lower ‘demand’, and a range of other characteristics of growing older … it does not surprise me that your F-i-L still insists that he ‘feels fine’.

As for struggling with technology … ask any >60 y/o to operate a (now-outmoded) video tape recorder, a CD player, a mobile phone - and you will be met with blank looks and a fast phone call to their 8 year old grandchild. Though perhaps true, I often wonder if is the pace of change, and not the change itself, which bemuses the older patient. Older patients dont so much have trouble learning something new as finding that, having just learned, the goal-posts are moved and they have to learn it all over again … and that is what wears down the will to try. But … that isn’t the case with dialysis technology: what they learn, becomes their rock. Dialysis technology doesnt continually ‘update’ or re-invent like, say, a mobile phone does. Once learnt, it stays, unaltered.

And, actually, the technology of a dialysis machine, especially those now available (or nearly so) for the home market isn’t all that complex. Some might have you think differently - protecting the ‘only-a-trained-health-professional-can-do-it’ mystique of dialysis in a cloak of ‘complexity’.

To that, I say ‘rubbish’.

Dialysis machines (especially the newer ones) now practically ‘load’ themselves and the treatment settings (parameters) can be largely ‘set’ and left. As with our cars - gone are the days of tinkering with the motor at home. Most modern vehicles, computer-driven and engine-boxed, are designed to stop inexpert fingers from gaining access to the important bits. That’s up to the technicians. We don’t have to know how the car works, we just have to be able to drive it safely.

I have a rule-of-thumb. If a patient drives a car, he can drive a dialysis machine. A driver needs to have good enough vision to see unaided - but a dialysis patient can use magnification. A driver must use both feet and both hands at once - often on separate tasks - while a dialysis patient is much more targeted in limb use. A driver needs dexterity, spacial awareness, must look ahead and behind, must be able to operate wheels, levers, and several bits of equipment at once … and converse … and change the radio dial or the CD cassette. A driver needs instant reaction, and rapid and repeated situation assessment and interpretation … else he/she will crash and burn. A dialysis patient always has much more time - even in an emergency - and requires far less multi-tasking. Conclusion? … if a patient can drive a car, then he/she can drive a dialysis machine. Now, I don’t know if your F-i-L drives, but I have a sneaky suspicion he may. If so, he’s a home trainee till proven otherwise!

So, no, I don’t ascribe to the ‘too old, can’t manage’ view that we traditionally place on our elders. I do ascribe to the ‘take it slow, make sure the ‘help’ systems are compatible with the patient, and don’t get too frustrated if it’s not picked up on the 1st run through’ approach. It is ‘we’ who are not relaxed about it. ‘They’ are.

And … re: 'help systems" … what I mean here is the prompt systems must suit the patient. Some will like a written manual, some will like pictures with captions, some will like a DVD system, some are visual learners, some auditory, some a mixture. Some will need their prompt systems translated into a different language. The ‘help’ system must be consistent with each patient’s optimum ‘learning’ and ‘understanding’ strengths. More work for the training unit? Yes. But, worth it. Finally, the home support offered by the training unit must be robust, available and always ‘there’. Here, companies are not involved in home support. We do the ‘supporting’ … the managing renal service … our home training nurses are the day-to-day ‘be there’s’ … our nephrologists have hands on day-to-day contact and involvement. Our machines are serviced by our unit-employed, unit-specific biomedical technicians … not a distant ‘I-don’t-actually-know-the-patient’ service crew.

At the end of the day, if he wants to give it a whirl … let him. The worst that can happen re the training process is that he may decide, through training, that it isn’t for him after-all. But I think you have to let him decide that for himself. I think our role is to offer, to support, to be there and not to judge ‘yes’ or ‘no’ but to simply let him try.

The key to successful training of the elderly - and I hope you don’t mind the use of that word for a late 70’s man - is not to rush the training. This is so, so, so important for the training unit to understand. Some will abandon training if it is not completed in ‘x’ days. Not so. Remember above all, let him train at is pace, his comfort, and he likely has the makings of a safe, committed dialysis patient, proud of his independence, strong in his self-esteem and empowered by his self-worth.

One last observation: you are an RN! you have been schooled, all your professional life, to ‘care for’ … it’s in your DNA now. When someone is ‘sick’, you care ‘for’ … it is anathema to us, in the health industry, to relinquish and/or suppress our ‘care for’ ethic when faced with a sick individual. Self-care isn’t something we are used to. One of the most potent barriers to more self-care dialysis is us! This is our mindset. It is ‘un-natural’ to relinquish care back to the patient. Yet … that is just what we do, in home dialysis. We often need to alter our own mindset more than we need to alter the patients’. It’s something to think about.

If he fails - even at the last hurdle - so be it. But at least he’ll have given it a shot. And, for many, that’s what counts most of all. Not to fail, but to have tried.

Re transplantation: I do not know your F-i-L but even not knowing, the risks of immunosuppression and of infective or other - primarily cardiac - complications in the older transplant patient are not insignificant. Here, I would have to defer to the intimate knowledge of him, as an individual, that only his treating team will have. But, I would be ‘iffy’ about transplantation in a late 70 y/o … and his team may well be right in suggesting this not be the optimum course.

Thank you so much for your detailed, thoughtful response! It really helps me have a much more open mind.

Great post John. My thinking these days is that really the only requirement for success, or the best predictor of success, is a desire to do the modality. If some one wants to do it, they should and everyone else should try to make it happen.

re: lone-dialyzed. I guess that makes me a lone dialyzor - I’ll buy a mask.

I couldn’t agree more. And would like to see the photo with the mask. :slight_smile:

Thanks, to you both. And, Bill, I may have to buy you a homely mask for the photo on your Facebook page!