Caring for the nursing home resident on dialysis: a search for solutions.

The need for nursing home placement of dialysis patients continues to escalate. Creative solutions are necessary to insure placement availability and optimal care of residents on dialysis once admitted. Communication between the nursing home and dialysis unit staff is key to reducing barriers to placement. The National Kidney Foundation of Michigan is currently intervening through the Nursing Home Manual to enhance training and communication.

Why is it difficult for staff to discuss advance directives with chronic dialysis patients?

General experience and reported data show that a substantial number of patients, at least 10% in many surveys, eventually choose to withdraw from chronic dialysis. There are additional studies suggesting that discussing and completing advance directives (AD) can promote more acceptance and less acrimony for patients, families, and staff when patients die. Even so, surprisingly few AD are completed, and dialysis staff often shun discussion of AD with patients. Thus, in this study, a survey of approximately 400 dialysis staff from 12 representative Michigan dialysis facilities was undertaken both to determine the beliefs, attitudes, and life experiences that might influence such discussions, as well as to guide future strategies aimed at encouraging the discussion and meaningful execution of AD. More than 50% (210) of the distributed questionnaires were completed. Overall results show that respondents report having discussed AD with only 30% of patients on average and that as many as 40% of respondents report never having done so. Among the professional disciplines responding to this survey, social workers report the largest percentage of patients with whom they discussed AD (60%), physicians a smaller percentage (38%), licensed practical (30%) and registered (25%) nurses even fewer patients, and dialysis technicians (20%) and dietitians (4%) the least. Across all disciplines, staff reported discussing AD with a larger percentage of patients when staff had experienced significant losses within their own personal lives, discussed such issues with friends or family, or had prepared their own AD. In rating specific barriers that correlated strongly with reported discussion of AD, each professional discipline had characteristic responses reflecting the approach of the discipline to addressing AD. The survey results suggest that the interdisciplinary variations observed are attributable to: (1) important differences not only in training, but also in the customary roles taken by each discipline; (2) inherent cultural differences, suggested by the findings among nonwhite staff of a lower reported frequency of having discussed AD with patients and of more concern over the barriers to doing so; and (3) a lack of support from supervisory and physician staff within the dialysis team. In conclusion, this survey shows, not surprisingly, that personal experiences and intrinsic cultural differences influence the attitudes of dialysis staff toward discussing AD with patients. The results of this survey underscore important differences between individual professional disciplines that affect both the perceived barriers to, as well as the likelihood of, discussing AD with patients. It seems that emotional issues such as death and dying stress interdisciplinary team interaction and amplify discomfort. However, it may be possible to increase the level of comfort in talking to patients about AD for each professional discipline by addressing the findings from this study (role differences and barriers) through focused interventions and by facilitating mutual support among the distinct members of the dialysis staff.