LIVING WITH A HAEMODIALYSIS MACHINE

The aim of the present study was to describe the experience of patients undergoing haemodialysis starting from their own perception. A qualitative perspective using Merleau Ponty's Existential Phenomenology was considered to be the most appropriate methodology for this study. Fifteen patients were interviewed in a haemodialysis unit at a Brazilian teaching hospital. Interviews were based on the question ‘What does the experience of living with a haemodialysis machine mean?’ Convergences in speeches were grouped into three categories: the machine, improvement in quality of life, reflection on patients' experience. These findings show the existential reality patients experience. A haemodialysis machine dictates their lives: they have to accept strict rules controlled by a team of healthcare providers. They realize it has to be so and there is no way out. It is the only way to get some relief from the symptoms of the disease. The feeling is mostly acceptance of the condition. Healthcare providers' dedication is recognized. Some participants complain about painful procedures, others deny them, others fantasize the reality. An essential piece of information is the lack of future perspectives; few patients mentioned the possibility of a transplant or the possibility of carrying out their own care. The study may contribute in outlining new perspectives for nurses to understand the needs of patients undergoing haemodialysis. An approach accepting patients' views will probably bring awareness to patients as to the possibilities of helping with their own treatment.     

The effect of profiling dialysate sodium and ultrafiltration on patient comfort and cardiovascular stability during haemodialysis

The aim of this study was to investigate what affect profiling dialysate sodium and ultrafiltration rate had on cardiovascular stability during haemodialysis, and if there was any effect on patients' fluid balance, thirst, serum sodium levels, blood pressure, or comfort and tolerance. The past decade has seen major advances in haemodialysis machine technology. Parallel developments have included profiling dialysate sodium levels and fluid removal during dialysis. However, some dialysis centres do not use profiling due to fears of long-term detrimental effects, especially with regard to hypertension and fluid control. Within my own workplace, approximately 30% of haemodialysis treatments utilise either sodium or ultrafiltration profiling, or a combination of both. Anecdotally, we have seen an increase in cardiovascular stability and haemodialysis tolerance. The aim of this study was to identify the effects of profiling haemodialysis, to ensure that the treatment we offer patients is safe and effective.     

Psychological care of the haemodialysis patient

The psychological care of patients at the haemodialysis unit is becoming an increasingly important aspect of the overall treatment of patients with end-stage renal failure. As more is understood and reported regarding the impact of psychological factors on physical processes it becomes crucial that good quality psychological care is delivered to patients by nurses working at the haemodialysis unit. This study aimed to look at haemodialysis patients' perceptions of their treatment to discover if a dialysis centre in Southern England might benefit from a more formal system of psychological care. The data revealed four main themes that were of particular importance to the participants of this study: The New Self, Coping, Medical Concerns and Psychological Care. Within these areas of importance, the need for good quality information, the need for a suitable dialysis environment and the importance of social and family support were evident. Although the psychological care system that was in place at the unit appeared to be working well a more formal system of care might improve the patient experience.     

A case study--initiation of haemodialysis

End-stage renal disease (ESRD) is a chronic failure of normal kidney function, which is precipitated by a number of factors, such as diabetes, pyelonephritis, hypertension, and polycystic kidney disease (1). The loss of kidney function is gradual, and many patients do not have any symptoms until the end-stage of the disease. Killingworth and Van Den Akker (2) point out that people undergoing haemodialysis have to comply with a wide range of medications and restrictions, which affect both their physiological and psychological status. This paper presents a case study of a woman with ESRD, requiring initiation of haemodialysis. An assessment of the patient's health needs is addressed, followed by the implementation and evaluation of the nursing process. Finally, the analysis of the overall plan used in the case study is presented.     

A CASE STUDY ‐ INITIATION OF HAEMODIALYSIS

End‐stage renal disease (ESRD) is a chronic failure of normal kidney function, which is precipitated by a number of factors, such as diabetes, pyelonephritis, hypertension, and polycystic kidney disease (1). The loss of kidney function is gradual, and many patients do not have any symptoms until the end‐stage of the disease. Killingworth and Van Den Akker (2) point out that people undergoing haemodialysis have to comply with a wide range of medications and restrictions, which affect both their physiological and psychological status. This paper presents a case study of a woman with ESRD, requiring initiation of haemodialysis. An assessment of the patient's health needs is addressed, followed by the implementation and evaluation of the nursing process. Finally, the analysis of the overall plan used in the case study is presented.     

Humour and dialysis

There are many articles on the connection between the spirit and the body and the influence of a good mood on the way people deal with physical problems. This paper will demonstrate that the use of humour is a way of influencing our patients' spirit in order to help them deal with problems relating to their illness. In our every day experience with renal patients, we have noticed that humour helps us reduce patients' anxiety, before the first dialysis, before using the dialysis needles, or before performing painful procedures. Humour also helps us to offset the anger patients often express during treatment. Humour brings about a better atmosphere and the possibility of creating positive communication with the patients in a more relaxed environment and in a much more effective way. Our findings are similar to those in the literature and conclude that humour is an aid for dealing with patients' problems.     

Problems about the management of active pulmonary tuberculosis patients undergoing haemodialysis--our experiences and nation-wide questionnaire survey

End-stage renal failure patients on chronic dialysis are high risk groups of tuberculosis due to attenuated cellular immunity. Patients receiving haemodialysis stay prolonged time inside the health-care facilities, thereby increased risk of tuberculosis transmission if a patient has active disease. So management of active pulmonary tuberculosis undergoing haemodialysis is important, however, the number of hospitals which are capable of taking care of such patients is estimated to be few in Japan. METHODS: From August 1994 through July 2002, 1059 active pulmonary tuberculosis patients (mean age; 57 +/- 19, male/female = 773/286) were admitted to Nishi-Kobe Medical Center, a 500-bed teaching hospital. Out of them, patients undergoing haemodialysis were retrospectively studied to describe the clinical characteristics of such cases. Then we conducted a questionnaire survey regarding the management of active pulmonary tuberculosis patients undergoing haemodialysis for 86 self-governing bodies in Japan. RESULTS: (1) Clinical characteristics of active pulmonary tuberculosis undergoing haemodialysis. We encountered 14 cases (mean age; 65 +/- 11, male/female = 7/7) of pulmonary tuberculosis undergoing haemodialysis during 8 years. In addition to pulmonary involvement, 3 pleural, one knee joint and one lymph node involvement was detected. Primary renal disease included diabetic nephropathy (n = 3), chronic glomerulonephritis (n = 3), congenital anomaly (n = 1), and unknown (n = 7). Nine cases were referred to our hospital from health-care facilities located out of city or prefecture. In five cases it took more than three months from the onset or detection of abnormal chest X-ray findings to the admission to our hospital. Five cases developed pulmonary tuberculosis within the first year after the initiation of dialysis. None of the patients had a past history of tuberculosis. Cavitary lesion on chest X-ray was observed in only one case. Triple antituberculosis therapy was used in 9 patients, and 4 antituberculosis drugs were used in 5 patients. Antituberculosis therapy was successfully done in all cases except two patients who died of apoplexy and cerebral infarction. (2) The nation-wide questionnaire survey. Of the 86 self-governing bodies we mailed, 66 self-governing bodies replied. Of them, 31% reported that they have experienced difficulties in the management of active pulmonary tuberculosis patients undergoing haemodialysis, and 25% reported the lack of health-care facilities to take care of such cases in their territory. They have referred such patients to hospitals located in the nearby prefectures or they have recommended antituberculosis therapy visiting a local haemodialysis facility. CONCLUSION: There are sometimes difficulties to manage active pulmonary tuberculosis patients undergoing haemodialysis in Japan. Health-care facilities to take care of such patients should be arranged and the formation of the network is necessarily.     

Rewarding medicine: good doctors and good behavior

Many patients think that there are shortcomings in the ethical dimensions of patient care, and research supports their view. In this issue of Annals, Erde suggests that physicians' incomes should depend on patients' assessments of their ethical behavior in much the same way that waiters' incomes depend on patrons' tips. Although Erde's solution is satiric, the problem is a serious one. The experiences and perspectives of patients regarding their own illness are undervalued by physicians. A truly patient-centered care demands that physicians elicit, understand, and respond to patients' perspectives. Tying physicians' pay to measurements of patient satisfaction is unlikely to dramatically improve the ethical quality of patient care as long as attention to the patient's perspective is seen as peripheral to "good medical care." Rather than relying on a single, easy "fix," we must re-examine all of professional development and practice. We need to choose persons for medical careers who will find patient-centered care rewarding; we need to provide such persons with training and socialization that underscores the value of personalized medicine; and we need to build institutions and systems that facilitate and reinforce patient-centered practice. The best ways to achieve these objectives are as yet unclear, but if we, as physicians, are offended by Erde's "modest proposal," then we must respond by proposing and implementing our own ideas about how patient care can become more humane.     

Nurse, haemodialysis, patient: is our caring based within a helping relationship?

Due to our experience in haemodialysis (HD) we became interested in evaluating the quality of care given during HD treatment. In May 1994, we conducted a cross sectional survey comparing the assessment of the total interaction between nurses and haemodialysis patients in a Lisbon dialysis facility. Our purpose was to identify nurses' and patients' opinion on the total interaction established during the dialysis treatment among both groups.     

Prospective follow-up study of hepatitis C virus infection in patients undergoing maintenance haemodialysis: Comparison among haemodialysis units

A prospective follow-up study on hepatitis C virus (HCV) infection was conducted in seven haemodialysis units from April 1990 to March 1995. A total of 634 patients were undergoing maintenance haemodialysis in the seven units. Of those, 302 patients participated in the follow-up study; 179 were initially HCV antibody negative and 123 were initially positive. Nine of the 179 initially negative patients became positive for HCV antibody during the follow-up period. In accordance with the appearance of HCV antibody, indicating new infection of HCV, all nine of these patients were diagnosed with HCV viraemia. As no other routes were apparent, HCV infection in all nine patients was likely due to nosocomial transmission. Prevalence of HCV antibody at the start of follow up was significantly higher ( P < 0.001) in haemodialysis units A-C (37.9%) than in haemodialysis units D-G (17.0%). Incidence of new HCV infection was significantly higher ( P = 0.005) in the former units (2.2% per year) than in the latter (0.2% per year). Ten of the 123 patients who were initially positive for the HCV antibody exhibited a loss of reactivity during the follow-up period; of these 10 patients, nine were negative for HCV-RNA from the start of the study. In conclusion, the incidence of new HCV infection seen in patients undergoing haemodialysis suggests that their risk of acquiring HCV infection is directly related to the prevalence of HCV antibody positive patients being treated in the units.     

Tuberculosis in the patients undergoing haemodialysis in Japan, 1996

We conducted a questionnaire survey on patients undergoing haemodialysis about the present situation of tuberculous incidence. They are immunocompromised hosts and are said to be at high risk of developing tuberculosis in many reports. (1) DESIGN Of the 167,192 patients on haemodialysis registered on December 31, 1996 in Japan, 71,411 patients were available for the questionnaire survey. Of the 2,893 hospitals used as the study subjects, 1,108 hospitals gave satisfactory replies. Of them, 141 hospitals reported that they had patients with tuberculosis in 1996, and 79 cases were collected by the detailed survey on tuberculosis patients conducted later. They included 45 male cases, 34 female cases for tuberculosis of all forms, 28 male cases, 15 female cases for pulmonary tuberculosis (PTB), 13 male cases, 4 female cases for tuberculosis bacilli positive pulmonary tuberculosis (TB positive PTB), and 17 male cases, 19 female cases for extrapulmonary tuberculosis. (2) RESULTS: In tuberculosis of all forms, the number of observed patients (O) against the number of patients expected (E) was calculated, and the standardized patients ratio (O/E ratio) was computed. It was 1.55 for male, 2.79 for female and 1.99 for total. The incidence of tuberculosis haemodialysis patients was significantly higher compared with the general population (p < 0.01). As to PTB, the O/E ratio was 1.01 for male, 1.40 for female and 1.16 for total; the incidence of PTB was not significantly higher compared with the general population. With TB positive PTB, the O/E ratio was 0.96 for male, 0.80 for female and 0.97 for total, and no significant difference was found. As for extrapulmonary tuberculosis, the O/E ratio was 13.45 for male, 13.07 for female and 12.97 for total; the incidence of extrapulmonary tuberculosis in haemodialysis patients was significantly higher (p < 0.01), but it was lower than these reported in the past literature. The seventy nine cases consisted of 52 primary treatment cases, 23 retreatment cases, and 4 unknown cases. Out of 79 cases, 36 cases developed tuberculosis almost at the same time or within 1 year after undergoing haemodialysis, and thereafter it decreased gradually. Underlying diseases for haemodialysis were mainly glomerulonephritis and diabetic nephropathy. There were many patients who failed to notify to the public health centers after the diagnosis of tuberculosis was made, and it is needed to improve such a situation in the future. The prognosis of tuberculosis undergoing haemodialysis was poor. Three out of 43 patients with PTB and 2 out of 13 tuberculosis pleurisy cases died. (3) CONCLUSION: The risk of developing PTB in patients undergoing haemodialysis was not high compared with the general population, however, the risk was much higher for extrapulmonary tuberculosis. Moreover, the treatment outcome was not satisfactory in patients with PTB and pleurisy. As patients undergoing haemodialysis have the factors which suppress the cell-mediated immunity, it is required to restudy the measures to prevent development of tuberculosis, management and treatment in the future.     

Patients' perspectives of fluid management: A multicentre comparative study of home and incentre haemodialysis

Background

There is increasing worldwide interest in person-centred care in haemodialysis and home haemodialysis (HHD). Intradialytic fluid management is a vital component of haemodialysis, and often a shared decision, yet patients' perspectives and experience of related decisions are largely unexplored.

Objectives

To explore the perspectives of patients receiving home or incentre haemodialysis (IHD), in relation to intradialytic fluid management.

Design

A multicentre cross-sectional survey.

Participants

Eight hundred and thirty-nine patients receiving IHD and 99 patients receiving HHD, across six English renal units.

Measurements

Self-reported measures of understanding, experiences and control of fluid management, and willingness to achieve target weight. An objective test of patients' ability to relate common signs and symptoms to fluid overload or excessive ultrafiltration.

Results

Patients receiving HHD had greater knowledge than those receiving IHD (66.1% vs. 42.3%, p < 0.001) about causes of common signs and symptoms which remained when controlling for age, education and years since beginning haemodialysis. Patients receiving HHD felt more in control of and had greater self-reported adherence to fluid management (p < 0.01), yet knowledge gaps existed in both cohorts.

Conclusions

Greater patient knowledge and its practice in HHD may contribute to improved fluid balance and outcomes. Whilst patient selection may contribute towards these differences, the training patients receive when opting for HHD and subsequent experience are likely to be key contributing factors. Integrating aspects of education on fluid management from HHD training programmes should be considered in IHD, and further targeted, robust education remains an unmet need.     

Quality of life perceived by chronic haemodialysis patients and family members

In this study quality of life perceived by 100 haemodialysis patients with family members' viewpoints on the patients' quality of life was studied. The SF-36 was used as the main measurement tool. According to the findings of the study the quality of life scores, perceived by patients, usually ranged between average and below average. The family members perceived patients' social functioning and functional status in the SF-36 more pessimistically but vitality and well-being in the SF-36 more optimistically, when compared to the patients. In the light of the findings obtained from the study, it is suggested to periodically assess the quality of life of haemodialysis patients considering the viewpoints of family members on the patients' quality of life.     

The assessment of values in laryngeal cancer: reliability of measurement methods

Although quantitative estimates of patients' attitudes toward the relative importance of different aspects of health are of great potential usefulness in medical decision making, there is little information about the stability of such values over time, particularly in patients whose clinical state is changing. To examine these questions, we selected a group of patients with laryngeal cancer undergoing treatment with radiotherapy. In this group of patients clinical problems are relatively circumscribed and related to the voice, and a temporary deterioration in voice-related symptoms and abilities is expected during treatment. Thirty patients were interviewed at the start and completion of a month's course of treatment. At each interview patients rated the quality of their own voices using a number of visual analogue scales and also provided both holistic and decomposed quantitative values for the importance of different aspects of voice function and sound. Although the analogue scales demonstrated the anticipated deterioration in the quality of the patients' voices, these changes in clinical state were not accompanied by any changes in the values the patients assigned to each aspect of voice sound and function. These results indicate that at least in the short term the values expressed by patients appear to be stable and uninfluenced by changes in their own clinical state. Longer term studies involving more systemic illnesses should now be carried out.     

Patients', physicians', and pharmacists' preferences towards coagulation factor concentrates to treat haemophilia with inhibitors: results from the COHIBA Study

Summary.  Despite modern highly efficacious technologies, there is still a lack of consensus on how to optimally treat haemophilia patients with inhibitors. The aim of the study was to evaluate preferences towards the characteristics of different coagulation factor concentrates for haemophilia inhibitors patients, from the perspective of patients or their caregivers, haematologists and pharmacists. A discrete choice study was conducted. Potential products were described with eight selected characteristics: perceived viral safety, risk of anamnestic response, possibility of undergoing major surgery, frequency of infusions in prophylaxis, number of infusions to stop bleeding, time to stop bleeding, time to pain recovery and cost. Participants received 16 pairs of potential products and chose from each pair the option they considered better. Data were analysed with a random-effects conditional logistic model. Totally 1614 observations were obtained from 37 patients/caregivers, 39 physicians and 25 pharmacists from Italy. Cost was the most important characteristic to every group. For patients/caregivers, the next most important factors were: risk of anamnestic response, possibility of undergoing major surgery and perceived viral safety. For physicians, the next most important characteristics were: risk of anamnestic response, number of infusions to stop bleeding and possibility of undergoing major surgery. For pharmacists, the next most important factors were: time to stop bleeding, time to pain recovery and possibility of undergoing major surgery. Decisions on treatments must take into account patients' clinical needs; however, preferences can also play an important role in the choice and success of treatments. The results of this study could, therefore, help decision-makers to optimize the overall benefits of treatments.     

Sex under the influence of alcohol among Norwegian adolescents

The purpose of this paper is to study alcohol consumption among Norwegian adolescents at their most recent experience of sexual intercourse. The material comprises a stratified sample of 920 adolescents aged 16–20 years in a Norwegian county (52.3% of the girls and 41.4% of the boys had coital experience). Data were collected by means of questionnaires; 21.0% of the adolescents reported sex under influence of alcohol. A logistic regression analysis showed that the best predictors of sex under influence of alcohol were intercourse location, sexual enjoyment and sexual intercourse motivated by “Don't know, it just turned out that way”. Adolescents who had their most recent experience of intercourse away from home, who had problems enjoying sex and/or who said it just turned out that way, were more likely than others to have had sex under influence of alcohol. A multivanate logistic regression analysis showed that among adolescents who reported that the intercourse took place away from their homes, the odds ratio (OR) for sex under influence of alcohol increased by 8. 7. Those who had consumed alcohol before sex, more often than non-drinkers, tended to enter into sexual intercourse motivated by factors external to their own person. This tendency was more pronounced among boys than girls.     

Stress, coping and quality of life among chronic haemodialysis patients

This study identifies the most significant stressors perceived by individuals undergoing haemodialysis due to chronic renal failure, the coping methods used most often by patients, and their quality of life. 75 patients aged 18-65 years old, and on regular haemodialysis for at least for one year were studied. Results showed that patients perceived high levels of stress, and that psychosocial stressors are as problematic as the physiological ones. Patients used problem-oriented coping methods more often than affective-oriented methods. Although their quality of life was satisfactory, patients were dissatisfied about their physical well being.     

Haemodialysing at home: the client experience of self-treatment

This paper reports a study that sought to describe the experience of people using home haemodialysis as their modality of renal replacement therapy. The study employed a critical interpretive methodology. After developing a framework for the research, a small group of renal clients who haemodialyse themselves in their own homes were intensively interviewed. This study describing the renal client perspective indicates that, although more demanding for them than in-centre treatment, self-treatment at home can enable a superior quality of life for many people living on dialysis.     

Critical care patients' perceptions of visits

Although visiting has been studied from nurses' and families' perspectives, patients' preferences for visits and their evaluations of visits have not been explored. In addition, coronary care unit (CCU) and surgical intensive care unit (SICU) patients' visit preferences have not been compared. Relationships among patients' preferences for visits, select personal and illness characteristics, and the perceived impact of visits were compared in a sample of 50 CCU and 50 SICU patients. Patients' preferences for the length of visits differed according to their age, particularly for CCU patients. Patients' preferences for the frequency of visits were similar to their usual preferences for being with others. Perceived illness severity, especially for SICU patients, was positively related to the preferred number of visitors. A greater proportion of SICU patients preferred visits any time, day or night, compared with CCU patients. Patients predominantly evaluated visits as helpful and not tiring. Results suggest the need to tailor visits to patients' preferences by considering personal and illness-related characteristics.