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When PD Is the Only Choice . . .
Christy Price Rabetoy, Department Editor
A Trusting Relationship Between Nurse and Patient Fosters Positive Outcomes!
Jeannine Farina, MSN, RN is Clinical Educator, Baxter Healthcare Corporation
McGaw Park, IL
Member, ANNA Three Rivers Chapter and ANNA PD SIG It’s
a situation experienced by most nephrology nurses working in peritoneal
dialysis (PD) – A patient previously on hemodialysis (HD) must transfer
to PD due to access failure. Not through his own volition, the patient
is forced to change modalities, and the pressure is on the nephrology
nurse to train this patient successfully. While this is a stressful
situation, it can be a positive opportunity for the nurse to educate,
allay fears, and provide patient support. By planning ahead, a positive
outcome can result.
Lemiere, Van Biesen, and Vanholder (2000) stated “to convince a patient
to start with PD requires mutual trust between the patient and renal
care team…. it takes time to build this relationship…” Unfortunately,
in this situation, time is limited. But, there are ways to foster this
mutual trust relationship quickly between nurse and patient.
One troubling issue, however, is the preconceived notion about PD that
the patient brings to the training. If the patient did not receive
adequate renal replacement therapies modality education, then his
source of information or misinformation may be from other patients on
HD who also have not performed PD. This misinformation tends to be
negative, creating patient fear of performing PD (DeHaan, 2003). One
way to correct the misinformation and build a trusting relationship is
for the nephrology nurse to encourage the patient to vent his fears and
concerns. This enables the nurse to understand the patient’s knowledge
and misconceptions about PD and to provide correct oral and written
information about the modality, potential issues, and advantages.
There are numerous benefits of PD when compared to HD. The sense of
autonomy a patient feels cannot be overemphasized during training; as
well as fewer diet restrictions; no needles required; and once training
is complete, only a monthly trip to the clinic versus three weekly
trips with HD. Patients quickly acclimate to home therapy and most
proceed forward with their previous lifestyles and activities. By
focusing on the benefits, the patient may be more willing to accept the
change from HD to PD. Providing the opportunity for current patients on
PD to talk with the transfer patient is often very helpful. This
provides numerous benefits, including discussing personal positive
experiences with PD, mentoring during the transition from HD to PD, and
being a support resource person for the patient (DeHaan, 2003).
Practitioners report that it is helpful to show the videotape, Enjoying
Life! Living Well on Peritoneal Dialysis (Baxter Healthcare
Corporation, 2003) before or during the PD training. The tape follows a
typical day of four diverse, healthy, and active patients on PD, who
tell their story of why PD is the right therapy for them. The tape, as
a result, can correct possible misconceptions and enables patients to
see that they can live productive, active lives on PD.
Patients can be successful in performing PD if there are dedicated and
experienced nephrology nurses who are supported by knowledgeable
physicians (Shetty & Oreopoulos, 2000). The nurses can deal with
issues effectively by establishing written protocols, evaluating the
training process, and monitoring patient outcomes via clinic and home
visits, phone call support, and continuous quality improvement.
Finally, nephrology nurses need to reinforce to all patients that the
best type of dialysis may change over time. By taking the above steps
when a patient needs to transfer from HD to PD, a trusting relationship
can be formed to help ensure successful patient outcomes.
References
Baxter Healthcare Corporation (Producer). (2003). Enjoying life! Living
well on peritoneal dialysis [Videotape]. Available from Baxter
Healthcare Corporation, 1620 Waukegan Road, McGaw Park, IL 60085-6730.
DeHaan, B.D. (2003). Why peritoneal dialysis should be the first treatment option. Dialysis & Transplantation, 32, 160-164.
Lameire, N., Van Biesen, W., & Vanholder, R. (2000). The role of
peritoneal dialysis as first modality in an integrative approach to
patients with end-stage renal disease. Peritoneal Dialysis
International, 20, S134-141.
Shetty, A., & Oreopoulos, D.G. (2000). Peritoneal dialysis: Its
indications and contraindications. Dialysis & Transplantation, 29,
71-77.
The Patient Switching from HD to PD Poses a Clinical and Emotional Dilemma
Maria Luongo, MSN, BA, RN is CAPD Nurse Manager, Center of Renal Education Nurse Manager
Massachusetts General Hospital
Boston, MA
Member, ANNA Mass Bay Chapter, and Chairperson, ANNA PD SIG
The patient struggling with
hemodialysis (HD) secondary to a failed vascular access poses a special
challenge to the nephrology nurse working with peritoneal dialysis (PD)
patients. The patient may come to PD after experiencing graft failure,
a clotted fistula or graft, sepsis, and/or stressful hospitalizations.
Emotionally exhausted and clinically compromised, the patient is often
angry, anxious, and ambivalent about starting PD.
A patient who elected HD as the first option for dialysis care and is
now forced to do PD in order to survive may be angry that HD was not
successful. Many patients on hemodialysis never receive education about
PD as a first option. So faced with HD failure, they may feel a duality
of betrayal; that is, PD was never offered as a first choice and HD is
unsuccessful. Lack of choice further complicates the patient’s
perception of care (De Haan, 2003). Fear, frustration, and distrust of
the health care system make the patient’s transition to PD problematic
and the role of the nephrology nurse more difficult (Bourne &
Garano, 2003).
Patient anxiety may focus on taking the responsibility for
self-dialysis and the distorted body image perceived by placement of an
abdominal catheter. As a patient on HD, it is necessary to participate
in the plan of care, that is, taking appropriate medications, following
nutritional guidelines, and attending scheduled HD sessions. However,
the patient on PD must actively assume a role of self-care and
self-responsibility. The anxiety coupled with anger is an overwhelming
barrier for the patient and the nephrology nurse at the initiation of
PD under these circumstances (Bourne & Garano, 2003).
The clinical dilemma is also a distinct challenge. Not only is the
nephrology nurse educating a reluctant patient to do self-care, but
this nurse must manage a patient who may be anuric and possibly
recovering from sepsis and malnutrition. Providing adequate dialysis
requires frequent prescription changes and careful monitoring. Patient
cooperation and adherence is crucial. The nephrology nurse must be
clinically and emotionally competent to manage this stressful
situation. Establishing a relationship with a reluctant patient
requires time, consistency, and expertise. The relationship that is
forged between patient and nurse is a very unique experience.
I agree with my colleague, Jeannine Farina, that this dilemma can be
the nurse’s “finest hour.” It is my opinion that nurses working in PD
are among the best patient advocates in health care. Providing the
education and empathy that patients require is inherent in nursing care
and daily PD practices. (Goleman, 1997). However, we must be mindful
and respectful of the emotional energy and clinical expertise needed to
provide care in less-than-ideal situations. Nurses are expected to
manage two groups of patients: patients who choose PD and patients who
must be on PD due to vascular access failure and other HD-related
problems. Advocating for appropriate education prior to initiation of
dialysis for patients is an expectation of proper chronic kidney
disease management. Recognizing the complex roles nephrology nurses
must fulfill when appropriate education is not provided would assist
nurses in maintaining their professional and career employment
satisfaction.
References
Bourne, E. & Garano,L. (2003). Coping with anxiety. Oakland, CA.: New Harbinger Publications, Inc.
DeHaan, B.D. (2003). Why peritoneal dialysis should be the first treatment option. Dialysis and Transplantation, 32(3), 160-164.
Goleman, D. (1997). Emotional intelligence. New York: Bantam Books.
Heaf, J. (2004, February 11). Underutilization of peritoneal dialysis.
Journal of the American Medical Association, 291, 740-742.
The Controversies in Nephrology Nursing
department focuses on exploring ethical and clinical issues within the
nephrology clinic practice in a point/counterpoint format. Address
correspondence to: Christy Price Rabetoy, Department Editor, through
the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ
08071-0056; (856) 256-2320; or by emailing her at
christycpr@comcast.net. You may also log onto this column at
www.nephrologynursingjournal.net (clink on Department link) and email
your comments to the Editor (see Discussion Area). The opinions and
assertions contained herein are the private views of the contributors
and do not necessarily reflect the views of the American Nephrology
Nurses' Association.
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