Renal rehabilitation: obstacles, progress, and prospects for the future.

The definition of rehabilitation for end-stage renal disease (ESRD) patients has changed significantly over the past 40 years. Initially, the concept focused on return to employment. In the early days, most members of the small, select group of patients chosen for dialysis met this criterion and were considered successfully rehabilitated. However, this "success" could not be replicated in the broader ESRD population when Medicare coverage was expanded to include older and more debilitated patients. This raised serious questions about the feasibility of renal rehabilitation efforts. Government policy makers and the nephrology community responded by (1) gathering data to enable the measurement and improvement of health-related quality of care, and (2) redefining rehabilitation and its goals. Today, renal rehabilitation is defined broadly, in terms of optimal functioning for individual patients and restoration to productive activities-not simply employment. To foster renal rehabilitation and guide program development, the Life Options Rehabilitation Advisory Council (LORAC) identified five core principles, called the "5 E's"-Encouragement, Education, Exercise, Employment, and Evaluation. Considerable progress has been made in measuring outcomes of care and in establishing a connection between rehabilitation interventions and improved outcomes. Increasingly, research is focused on the relationship between patient self-reports and health status outcomes. In the years ahead, clinicians and researchers will see growing evidence of relationships between specific rehabilitation interventions, improved outcomes (including health-related quality of life), and cost-effective delivery of care.

Home hemodialysis: survival, quality of life, and rehabilitation.

Choice of treatment modality for patients with end-stage renal disease ideally should not only increase the chances of survival but also improve quality of life and facilitate rehabilitation goals. These goals include employment, enhanced physical functioning, improved understanding of dialysis, increased control, and resumption of activities enjoyed before dialysis. Home hemodialysis has been consistently associated with improved long-term patient survival and quality of life compared with patients treated with in-center hemodialysis or peritoneal dialysis. Home hemodialysis is also well suited to rehabilitation. Home hemodialysis training programs educate patients and partners to become responsible for dialysis treatments, thus encouraging independence and permitting flexible scheduling, which promotes greater participation in exercise and employment. Further information about modality choice and rehabilitation outcomes could be obtained by systematic data collection to enable comparisons between modalities. Patients should have the opportunity to choose from among all modalities, including home hemodialysis.

Differences between employed and nonemployed dialysis patients.

Three hundred fifty-nine chronic dialysis patients (85 employed and 274 nonemployed) were surveyed to identify/verify those characteristics which differentiate between employed versus nonemployed status. Education emerged as a significant correlate of employment, as noted by previous investigators, whereas, unlike previous research, neither mode of dialysis, length of time on dialysis, number of comorbid conditions, nor cause of renal failure (eg, diabetes) were associated with employment status. Measures of functional status (MOS SF-20 and Karnofsky) were positively associated with employment. Furthermore, patients' perceptions that their health limited the type and amount of work that they could do were negatively associated with employment. In addition, using a series of de novo items, we found subjects' beliefs about dialysis patients' ability to work to be a "self-fulfilling prophecy" with regard to employment status. That is, patients who themselves believed that dialysis patients should work and had this notion reinforced by significant others were more likely to be employed. Interestingly, 21 percent of unemployed patients reported that they were both able to work and wanted to return to work. Because it is consistently reported that only a small percentage of dialysis patients are employed, targeting the patients who are both willing and able to work for vocational rehabilitation might significantly increase the numbers of employed dialysis patients.

Nursing interventions for rehabilitating renal patients.

Of the more than 180,000 Americans who have end stage renal disease (ESRD), only 25% of those of working age (18-55) are employed. This figure has remained low despite improvements in technology and pharmacology. In 1993, a Life Options Rehabilitation Advisory Council identified five areas that must be targeted to achieve rehabilitation success: employment, exercise, education, encouragement and evaluation (the 5 E's). This article addresses nursing interventions for rehabilitation related to these five E's.