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Home Hemodialysis: Patient Selection and the Importance of Informed Choice Dr. Robert Lockridge P/N 102989-01 Rev A 02/2016 © 2016 Fresenius Medical Care, All Rights Reserved. Course Disclosure • This educational program has been developed by the Medical Information and Communication Office of the Fresenius Medical Care Renal Therapies Group. • It is intended to provide pertinent data to assist health care professionals in forming their own conclusions and making decisions. • It is not intended to replace the judgment or experience of the attending physician or other medical professional. • The treatment prescription is the sole responsibility of the attending physician. 2 Learning Objectives Understand that informed choice is a medical and ethical obligation of healthcare providers and a tool for assisting dialysis patients in selecting the best modality for them Identify factors used by healthcare professionals to select patients for home hemodialysis (HHD) Recognize factors used by patients when choosing home hemodialysis as an option 3 Course Outline • The importance of informed choice • Addressing patient barriers to home HD • Selecting the right patients for home HD • Home HD Training • Summary 4 Introduction • Utilization of home hemodialysis (HHD) in the US is low (1.8%) • Significant barriers seem to exist that prevent or minimize the use of HHD • Comprehensive education on HHD for medical staff, patients, and caregivers can help circumvent these barriers Young BA, et al. Clin J Am Soc Nephrol. 2012;7(12):2023-32 5 Informed Choice 6 Discussion How would you best define “informed choice” for patients starting dialysis? A communication between a patient and physician that results in the patient agreeing to undergo dialysis A physician responsibility An ethical obligation and a legal requirement of physicians Discussion of the nature and purpose of dialysis treatment with the risks and benefits with the patient Discussion with the patient of alternative renal replacement treatment options with risks and benefits The risks and benefits of not receiving or undergoing dialysis All of the above K/DOQI. Am J Kidney Dis. 2006;48 Suppl 1:S2-S90, Goovaerts T, et al. J Ren Care. 2015;41(1):62-75 Saggi SJ, et al. Nat Rev Nephrol. 2012;8(7):381-389, Ribitsch W, et al. Perit Dial Int. 2013;33(4):367-371 7 Informed Choice Obstacles to Home Hemodialysis • Historically, up to 88% of patients in the US reported being unaware that HHD was an option • Lack of modality education typically leads to in-center HD as the default modality, particularly for late-referred patients • Quality of education, extent of patient involvement, patient comprehension, and amount of time spent discussing treatment options are important determinants of patient perceptions Young BA, et al. Clin J Am Soc Nephrol. 2012;7(12):2023-32 Mehrotra R, et al. Kidney Int. 2005;68378–390 8 Do patients feel informed? Condition that led to kidney failure How long you would live with or without dialysis Dialysis options (including PD and HHD) Benefits and burdens associated with each type of dialysis Doctor asked your values and preferences for those dialysis options How your daily life might change after starting dialysis Need for dialysis for the rest of your life unless you receive a kidney transplantation Not starting dialysis could be an option Doctor tired to make sure you understood what he/she told you Doctor tried to understand what was important to you Song M-K, et al. Nephrol Dial Transplant. 2013;28(11):2815-2823 Patient-Related Barriers to Home HD Situational Motivational Fear-Based Cafazzo JA, et al. Clin J Am Soc Nephrol. 2009;4(4):784-9 Pipkin M, et al. Clin J Am Soc Nephrol. 2010;5(9):1614-20 Young BA, et al. Clin J Am Soc Nephrol. 2012;7(12):2023-32 10 Situational Barriers Inadequate housing Inadequate water Inadequate family or social support Can be difficult or impossible to overcome, even for patients who have the desire to do home HD. Cafazzo JA, et al. Clin J Am Soc Nephrol. 2009;4(4):784-9 Pipkin M, et al. Clin J Am Soc Nephrol. 2010;5(9):1614-20 Young BA, et al. Clin J Am Soc Nephrol. 2012;7(12):2023-32 11 Motivational Barriers Lack of motivation Comfortable with in-center routine Training is too long and intense Can often be overcome using focused strategies and informed choice Cafazzo JA, et al. Clin J Am Soc Nephrol. 2009;4(4):784-9 Pipkin M, et al. Clin J Am Soc Nephrol. 2010;5(9):1614-20 Young BA, et al. Clin J Am Soc Nephrol. 2012;7(12):2023-32 12 Fear Based Fear of cannulation Fear of needle dislodgement Fear of ability to sleep Fear of machine Fear of inability to learn procedures Fear of intradialytic hypotension Fear of not being monitored by professionals Fear of hurting self Addressing fears early in the process may mitigate their influence on the patient’s decision Cafazzo JA, et al. Clin J Am Soc Nephrol. 2009;4(4):784-9 Pipkin M, et al. Clin J Am Soc Nephrol. 2010;5(9):1614-20 Young BA, et al. Clin J Am Soc Nephrol. 2012;7(12):2023-32 13 Urgent Start to Home HD An in-hospital CKD education program can increase home HD utilization 132 in-center hemodialysis 228 Acute Start Patients Education program before hospital discharge 22 Home HD 71 home dialysis 25 died before discharge 49 PD Rioux J-P, et al. Clin J Am Soc Nephrol. 2011;6(4):799-804 14 Home HD Patient Selection 15 Informed Choice Tools for Patient Selection • With all modalities, having the patient choose the right modality for them is key • Available Tools: – Match-D: a tool that makes it easy for healthcare providers to assess candidates for HHD – My Life, My Dialysis Choice: a tool for patients and their families to evaluate the different dialysis modality options 16 For Healthcare Providers: HHD patient selection using MATCH-D • MATCH-D (Methods to Assess Treatment Choices for Home Dialysis) is a tool that makes it easy to assess candidates for HHD • Match D defines three patient categories – Category 1: Strongly encourage HHD • Shows triage criteria for patients who should do HHD – Category 2: Encourage HHD after assessing and eliminating barriers • Suggests solutions to common home dialysis barriers – Category 3: May not be able to do HHD • Presents potential contraindications for independent home treatment, some of which may be overcome with support by a caregiver Methods to Assess Treatment Choices for Home Dialysis, Version 4.; 2013 17 For Healthcare Providers: MATCH-D Methods to Assess Treatment Choices for Home Dialysis, Version 4.; 2013 18 For Patients: My Life, My Dialysis Choice 19 My Life, My Dialysis Choice 20 My Life, My Dialysis Choice 21 My Life, My Dialysis Choice 22 Three Factors That Count • Informed choice for the patient • Motivation for performing dialysis at home – – – – – Control of healthcare Medical reasons for more frequent therapy Time commitment and flexibility Distance from dialysis center Many others • Social support (not effort) at home – ESRD is a hard journey – Patients who perform more of their treatment themselves have greater retention 23 Discussion Home HD may be best for patients who… Want greater flexibility Cannot or don’t want to travel to a dialysis center Work full-time or part-time Desire less dietary and fluid restrictions Want more privacy Are dissatisfied with current therapy Want to tailor their treatment to their lifestyle needs Want to address certain medical conditions that may be improved with home HD K/DOQI. Am J Kidney Dis. 2006;48 Suppl 1:S2-S90, Goovaerts T, et al. J Ren Care. 2015;41(1):62-75 Saggi SJ, et al. Nat Rev Nephrol. 2012;8(7):381-389, Ribitsch W, et al. Perit Dial Int. 2013;33(4):367-371 24 Who should not do HHD? • • • • • • 25 Drug addicts Alcoholics Major mental illness Homeless person Medical illness that prevents care at home A patient that does not have adequate social support Discussion Which of the following patients could benefit from home HD? Patients on in-center HD or PD that have “lost hope” for the future Patients that have retired, who had plans of things to do during retirement, and now are starting dialysis Patients on in-center HD who routinely become hypotensive, develop cramps, nausea, vomiting and headaches during dialysis Patients who are failing PD Patients with cirrhosis, hypotension, and ascites Patients with excessive weight gain between treatments Patients whose blood pressure can not be controlled Patients whose phosphorus can not be controlled Patients with CHF, chronic hypotension, or congestive cardiomyopathy Patients who are starting dialysis that can not be transplanted K/DOQI. Am J Kidney Dis. 2006;48 Suppl 1:S2-S90, Goovaerts T, et al. J Ren Care. 2015;41(1):62-75 Saggi SJ, et al. Nat Rev Nephrol. 2012;8(7):381-389, Ribitsch W, et al. Perit Dial Int. 2013;33(4):367-371 26 Training Home HD Patients 27 Possible Procedure for Evaluating Patients for Home HD • Patient and patient caregiver meet with nurse, social worker, and referring nephrologist • Home visit by nurse and machine technician • Meeting of home training team to include nurse, social worker, dietitian, technician, and nephrologist to access if patient is a candidate, identify possible barriers to HHD, and how to mitigate these barriers • If patient is a candidate, give patient a date when the patient will start training for HHD 28 Keys Points About HHD to Understand at the Beginning of Training • The first 3 months of the patient dialyzing at home are the most critical in determining if they remain at home • Training schedule will be determined by needs of patient, caregiver and provider – At the beginning of training patient, caregiver and nurse will decide who will do what in performing HHD • Length of training will be determined by nurse when patient is component in all areas of HHD • Patient will be informed on possible personal financial cost for do HHD Young BA, et al. Clin J Am Soc Nephrol. 2012;7(12):2023-32 29 Home Hemodialysis Training • Should be standardized for efficiency but individualized to each patient • Patients should be trained in the following: – Dialysis machine • User manuals – Machine/equipment maintenance • User manuals, tech support numbers – Water system • RO system, if applicable • Quality testing – Particularly for chloramines – Use of routine procedures to maintain adequate water quality standards – Should be done prior to every session Moran J, Kraus M. Semin Dial. 2007;20(1):35-39 Hawley CM, et al. Hemodial Int. 2008;12 Suppl 1:S21-S25 30 Home Hemodialysis Training • Patients should also be trained in the following: – – – – – – – Cannulation/needling Access care Administering medications (e.g., EPO, heparin) Ancillary monitoring equipment Handling complications and emergencies Ordering supplies Waste disposal Moran J, Kraus M. Semin Dial. 2007;20(1):35-39 31 Home Hemodialysis Training • Partners should also undergo training – Patients should perform as much of the HHD treatment as possible based on their physical and mental capabilities – The partner should be trained in what is appropriate to support the patient but must be competent in: • Emergency take off • Addressing alarms in conjunction with the patient • Accessing the patients status when help is needed Moran J, Kraus M. Semin Dial. 2007;20(1):35-39 Young BA, et al. Clin J Am Soc Nephrol. 2012;7(12):2023-32 32 Home Hemodialysis Training • Ideally, patients and partners should perform a number of dialysis sessions in the training center without assistance – Confirms their independence – Confirms their ability to perform treatment at home • May be helpful for a training nurse to be present during the first few treatments at home • Communication with dialysis unit, nurses, and physicians should be stressed and maintained – Nurse and patient communicate before start and after each HHD treatment for the first 2 weeks – On-call support 24/7, patient encouraged to call if having concerns about any aspect of treatment – Frequency of clinic visit in first 2 months is variable, after that monthly Moran J, Kraus M. Semin Dial. 2007;20(1):35-39 Young BA, et al. Clin J Am Soc Nephrol. 2012;7(12):2023-32 33 Post-Training Expectations • At the end of training, the patient should be able to: Perform the HD treatment per the physician’s prescription Draw blood to be sent for routine testing Turn in home treatment logs regularly as required Manage complications appropriately Contact the facility and/or the manufacturer with machine questions, concerns or problems – Agree to weekly visits for the first month, every other week for the second month and monthly or at least every other month ever after – Order supplies on time – – – – – • HHD can help to – Encourage patient independence, responsibility, and confidence – Increase comfort, convenience, outcomes and quality of life Young BA, et al. Clin J Am Soc Nephrol. 2012;7(12)2023-32. 34 Summary • Informed choice is a medical and ethical responsibility of healthcare providers • Informed choice can be used to overcome many patient barriers to home hemodialysis • There are patient modality selection tools for healthcare providers and patients • Home HD training should be standardized for efficiency but individualized to each patient and caregiver 35 Fresenius Renal Therapies Group, a division of Fresenius Medical Care North America 920 Winter Street • Waltham, MA 02451 Fresenius Medical Care, the triangle logo, the Advanced Renal Education Program, and the AREP logo are trademarks of Fresenius Medical Care Holdings, Inc., or its affiliated companies. © 2016 Fresenius Medical Care, All Rights Reserved. P/N 102989-01 Rev A 02/2016 36