On a fairly regular basis, we see debates about prescriptions, or how
dialysis prescriptions are “supposed” to look on our (and other) social
media. There is controversy at every level in the industry about
the “right” way to do things. There are also absolutely
multiple “camps” of beliefs among providers, nurses, and patients—and
tons of variations in practice.
I commented on one of our message board posts about prescription
differences recently, and it was suggested that I turn my comment into a
post of its own. Sure. No problem… This is where I am going to go ahead
and remind everyone that medicine is both an art and a
science.
Let’s Start with PD?
A lot of people firmly believe in a PD-first approach, but many will
begin to disagree over whether training (and ultimately prescription)
should be for manual and then automated—one or
both?
Dose is another topic. One group
inevitably argues that incremental PD is the “right” way, with an
emphasis on utilizing and preserving residual function for as long as
possible. Others favor full-dose PD at onset, with the option to “maybe
back down” at a later time. Add in the mumbled voices from the back that
inform everyone that PD isn’t very good at removing B2M
and that can only be a trade-off with the benefits of residual function
preservation for so long.
Things Are Even
More Chaotic on the HD Side
A lot of folks lately seem
really into the idea of treating home dialysis like it’s standard
in-center treatment, just…at home. Some patients have equipment and
sufficient supplies at home to run safer treatments and completely avoid
2-day gaps—but are encouraged to run on a thrice weekly schedule, with
no additional time. I find this concerning.
If a home HD treatment is performed in the exact same way as an
in-center treatment…is there any health benefit other than a
cozier location? Does that fall into the realm of personal
choice? Are the chances of an emergency happening (you know, the scary
things like sudden cardiac death) just as high if not
higher when this is being done? I’m not sure. It really worries
me for our industry though.
Patient blood flow rates at home are always a hot topic. I was
speaking with another nurse recently and we discussed the highest
prescribed BFR we’d ever seen. Mine was 550 on 14g needles. Hers
was 600! Both of these numbers are completely shocking and 
outrageous
to me. Just thinking about them gives me anxiety!
One reason I left clinical nursing was the ethical dilemma I
had over frequent orders calling for high BFRs after reading
John Agar’s blog, Don’t
Flog the Fistula. I don’t think numbers like that belong at
home—or in-center. I see the concepts described in that
original blog and have been deeply affected by them.
Some
clinics encourage rigid home HD treatment
schedules—even to the point where total ultrafiltration volume
is pre-set to an average, and patients do not understand how to make
adjustments, regardless of their fluid status. Hypotension
from pulling too much fluid should never happen at
home—or in-center—and these scenarios seem like a perfect storm
for exactly that.
There are also patients who do not know (or are not permitted) to
lengthen their treatment time for the purposes of lowering their
ultrafiltration rate (UFR). These are fundamental
concepts. Being aware of UFR and the dangers of organ stunning
is something we have made quite easy for patients to do from home—and
it’s FREE.
Patients deserve this information.
In some programs, patients are actively encouraged to do more
frequent treatments and have different schedules based on what works
best for them. We talk to patients who treat every
other day, and we talk to patients who treat every
day. Everything in between exists, too.
There are people who have busy lives and have managed to work out how
to have multiple dialysis order options—depending on what they feel like
and have time for. There can be long home HD treatments, short
home HD treatments, and “just right” home HD treatments. Often
these same patients have been shown how to adjust for time and UFR and
understand the reasons for doing so.
Some home HD programs do not allow patients to treat without
partners, or do nocturnal HD even with a partner—and encourage
so-called “caregivers” (we prefer “care partners”) to be very
actively involved in treatment—more so than the patient, even when
the patient is capable. This can harm couple relationships,
as co-dependence and burn-out creeps in. At least
that’s what I’ve seen. Established home programs with well-trained
nurses speak fondly of nocturnal home HD as a “gold standard” in the
good old days and reminisce constantly about how the treatment was so
good, “we had to give them back phosphorus!”
“More is always
better” is just as incorrect as “less is always
more.“ Neither statement takes into account
the human involved. People are not sets of labs. Who are each of your
patients? What do they value? What do they want? What are they willing
to do? How do they feel about what is happening? How can we help meet
those needs?
A “correct” dialysis prescription is specific to individual
preferences, physiology, needs, and wants. Different patients have
different goals of care and primary concerns and deserve to weigh these
kinds of decisions in the most informed manner possible. We have
the flexibility in home dialysis to customize and be creative for the
sake of quality of life. This is the art part. The freedom to
do these things in an individualized way: to analyze, tweak, debate, and
perfect for each person is one of the under-lying goals of home
therapies.
If a person’s focus is only on quality of life and “enjoying
life” is defined by not doing a lot of treatment, then sure, one option
is to reduce treatment time and/or frequency and let symptoms be the
guide. A person can replace just enough function to feel well enough to
carry about with their business as they had been. There is nothing wrong
with that, as long as the patient is the one weighing the pros
and cons with a clear and informed mind. This might be a
fantastic choice for some patients—and a disastrous one for others.
A different person might want to focus on systemic
preservation and physiologic stability. That person might
really value living for as long as possible with fewer irreversible
complications. They might want to not limit their diet at all, ever. If
that’s the case, then slower/longer/more frequent
treatments make the most sense.
Flexibility in practice is the only real way to meet the
needs of all of the patients in a home population. Part of the
art is finding a treatment “sweet spot” that allows patients to live
life to the fullest on their own terms. When at home, we should err on
the side of limiting complications always.
This means really
incorporating things like low UFRs, longer treatment, slower BFRs, more
frequent treatment, etc., into our culture.
Anyone want to pick a hill to advocate on yet? If
so, please do so in comments. ☺
- The Renal Warrior Project. Join Now
- Source: https://homedialysis.org/news-and-research/blog/592-prescribing-debates-in-home-dialysis