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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
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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
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For Healthcare Providers:
MATCH-D
Methods to Assess Treatment Choices for Home Dialysis, Version 4.; 2013
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For Patients:
My Life, My Dialysis Choice
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My Life, My Dialysis Choice
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My Life, My Dialysis Choice
21
My Life, My Dialysis Choice
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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
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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?
•
•
•
•
•
•
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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
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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
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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
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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