Home Dialysis: Patient Selection and Psychosocial Support

Home Dialysis: Patient Selection and Psychosocial Support

Which patients might benefit from home dialysis? Clinically, virtually all of them—a fact that nephrologists know given that only 6 percent of them would choose standard in-center hemodialysis (HD), done in a clinic thrice weekly for 3 to 4 hours, if their own kidneys were to fail (1). There is clearly an enormous disconnect between knowledge and practice, inasmuch as more than 90 percent of American patients with kidney failure are prescribed the treatment most nephrologists would not choose for themselves. Perhaps a broader perspective about suitable candidates—and tools to help match patients with an option that will best suit their lives and values—will improve the uptake of home therapies. It’s time to try.

Lifestyle impact of dialysis

Dialysis is far more than a medical treatment. It can disrupt lifestyles on every level, from what patients can eat and drink to their energy level and day-to-day symptoms, their sleep, their ability to keep their jobs and travel, their sexuality and fertility, and ultimately their survival. Each patient has a life: places to go, things to do, others to take care of. We need to recognize that in giving life we may also be taking lifestyles away, and precipitating depression and hopelessness. In fact, stopping treatment because of sheer misery is a leading cause of death in patients receiving HD.

Consider Delores. An African American attorney in her 50s with type 2 diabetes, she was warned about impending kidney failure but was too afraid to take action. She also did not know there were options that could have allowed her to keep her job and care for her autistic son. She began standard in-center HD emergently with a chest catheter. Her clinic advised her to take disability. So she gave up her job, prompting fears about how she would care for her son with 70 percent less income. At no point was she asked about her values or preferences, nor was she told that there were other options.

Motivation for home HD

The single most vital factor in patient selection for home HD is motivation. But you can’t tell whether someone is motivated by looking at external factors like age, ethnicity, clothing, or speech patterns. Patients like Delores are motivated because they have a lifestyle that matters to them. The only way to learn how motivated patients are is to ask them, and to listen when they request a certain option. Typically, patients who do this have done their homework and will succeed.

Some patients are able to do their treatments independently, and lack of a care partner should not be a barrier to home HD for them. When a clinician prescribes solo therapy, dialysis clinics will support that choice. The United States is the only industrialized nation that requires care partners for home HD, and clinics have an unfortunate tendency to turn care partners into dialysis technicians who are supposed to do all of the dialysis tasks. In particular, inserting the needles is a task that should be done by the patient if at all possible, because care partners find it highly aversive and stressful. Some frail, debilitated patients whose families prefer to care for them at home need a high level of care. But for capable patients this assumption is a recipe for failure, and empowering them to administer self-dialysis can be safe and effective.

Tools to help clinicians succeed

The nonprofit Medical Education Institute has developed several tools to help clinicians and patients match treatment options to patient preferences. They include the following:

  • Method to Assess Treatment Choices for Home Dialysis (MATCH-D). Free guide to help clinicians see which patients should be encouraged to do home HD, which might need help to overcome challenges, and which are not candidates. www.homedialysis.org/match-d.
  • Help, I Need Dialysis! Comprehensive, fully referenced book explains the impact of each dialysis option—including home HD—on lifestyle. www.lifeoptions.org/help_book.
  • My Life, My Dialysis Choice. Free decision aid lets patients choose key lifestyle and health values, then see how each value might be affected by each of four dialysis options, including home HD. Using this tool first may help improve the conversation about dialysis options between nephrologists and patients by routing around denial and fear. www.mydialysischoice.org.
  • How to Have a Good Future with Kidney Disease. Free six-deck slide toolkit for education about chronic kidney disease with learning objectives, speaker’s notes, quizzes, and handouts that can be used for billing under the Medicare Improvements for Patients and Providers Act. Not copyrighted, and can be adapted. www.lifeoptions.org/goodfuture.

Psychosocial support at home

Once at home, patients and care partners (if present) may be more likely to succeed if they receive some straightforward psychosocial support from the clinic. This can include ensuring during training that patients feel competent to complete the treatments and handle any troubleshooting that arises, making proactive phone call check-ins at home to see whether there are questions, connecting patients with other home patients in the area or online, and offering respite care in the center or with a visiting nurse to give the patient, care partner, or both periodic breaks. The first several months at home are an especially vulnerable time. Somewhat like bringing home a new infant, it takes time to physically integrate the equipment and supplies into the home and to sort out the tasks of home HD and get into a comfortable routine. Patients who make it through the first several months are likely to continue.

If we help patients understand how home HD may fit their lives and their goals, seek motivated patients, and give them the tools they need to succeed, we can grow home HD and allow more patients to enjoy its many benefits.

ASN Kidney News gratefully acknowledges the editor of this special section, Christopher T. Chan, MD, FRCPC, for his contributions to this issue.

Reference

1. Merighi JR, et al. Insights into nephrologist training, clinical practice, and dialysis choice. Hemodial Int 2012; 16:242-251.