By Debra Wood, RN, contributor
Evidence suggests home hemodialysis offers select renal-failure patients improved quality of life. Nurses play a key role in evaluating appropriate candidates, teaching them and their caregivers to proficiently deliver the treatments, and monitoring their progress.
“They look better; they feel better,” said Eileen MacFarlane, RN, BSN, CNN, an executive committee member of the National Kidney Foundation’s Council of Nephrology Nurses and Technicians, and a home therapy nurse manager for WellBound of Mercer in Hamilton, N.J., a part of Satellite HealthCare. “You would never know my patients are dialysis patients. Their color is great. With daily home hemo, you have a steady state.”
Cindy Barclay, RN, started her own company to offer home hemodialysis. She also has written a book about the uncertainty and the frustration of living with renal failure and dialysis.
Home hemodialysis patients may dialyze six days per week for up to three hours, although other centers may teach them to dialyze every other day. Patients may also dialyze during the night, while they sleep.
“It allows them to eat a regular diet and drink more fluid, because it’s more like normal kidney function,” said Cathy Cox, RN, CNN, a home hemodialysis training nurse at Clarian Health in Indiana. “They sleep better. They feel better, have more energy and take less blood pressure medicine. All of those things added up give them a much more normal life.”
Cox says home hemodialysis candidates are usually motivated to become more independent. Many of them work or attend school. Patients can change the time they dialyze and travel with their machines.
The portable NxStage System One units, used by Clarian, weigh about 75 pounds and are the size of a 13-inch television set. They require no special electrical service or water system. The hook-up is simple because of a one-stage cartridge system.
“With home hemodialysis, the patient can be in control of the treatment,” said Debra Thompson, RN, home therapies coordinator for Fresenius Medical Care in Orlando. “When we give control back to the patient, they benefit so much. Their lab results improve. They become more adequately dialyzed. Their lifestyle improves. They have more energy and feel part of the community again.”
Cindy Barclay, RN, founder of Quality Dialysis of Houston and author a book on living with renal failure entitled That Damn Dialysis, also finds home hemodialysis serves as an educational tool, which can inspire family members to improve their diets and manage their blood pressure or diabetes.
A study by Southern California Kaiser Permanente Medical Group, reported in the October 2008 American Journal of Kidney Diseases, found that the extra cost of providing in-home hemodialysis, compared to peritoneal dialysis was balanced out by lower expenditures for medications and hospital admissions in the hemodialysis group.
Eileen MacFarlane, RN, BSN, CNN, said home hemodialysis allows renal-failure patients to achieve a more steady state than in-center dialysis.
A 2007 study out of Indiana University Hospital in Indianapolis found that home hemodialysis patients had lower blood pressure, less need for antihypertensive medications, and less interdialytic weight gain than patients receiving dialysis at a center. The researchers concluded that daily home hemodialysis with a small, easy-to-use device is a viable dialysis option for end-stage renal disease patients capable of self- or partner-administered dialysis.
Patients, typically, must have a willing caregiver available to assist and provide emergency care.
“We assess them for how strong the relationship is,” Cox said. “This is a very stressful thing, going through training and being on dialysis.”
Cox makes it clear from the onset that the patient needs to participate and do much of the work. She lets candidates talk with other patients who successfully dialyze at home.
“The other patients like to be able to say, ‘I did this and was just as scared as you are, but look at me now,’” Cox said.
Nurses often train home hemodialysis patients in a center while they undergo treatment. Training takes place on a daily basis for three to five weeks. The patients and their caregivers learn about the disease process, diet, medications, required lab work, setting up and tearing down the machine, determining how much fluid to remove at each session, monitoring blood pressure during dialysis, responding to alarms, and other self-care interventions.
As training winds down, the nurses back off and let the patients do more and more on their own, just as they would at home. Throughout the program, nurses encourage patients and build their confidence.
Quality Dialysis nurses train patients in the home. Private insurers often cover the cost, but Medicare does not. It takes patients about 12 weeks to complete the course. The nurse will simulate emergencies, such as turning off the power, to teach patients how to deal with different situations.
“We make sure when we leave you know what you are doing,” Barclay said.
At all of the programs NurseZone talked with, nurses are available by telephone 24 hours a day to assist with troubleshooting alarms or adjusting treatments. These on-call nurses usually have extensive hemodialysis experience.
The NxStage System One home dialysis unit is about the size of a 13-inch television.
Patients, generally, return to their nephrology clinic monthly for evaluation where nurses and physicians meet with them. In addition, nurses visit the home annually.
“We look to make sure supplies are stored correctly, that the patient is doing the treatment as prescribed,” Thompson said. The nurses also assess home equipment and medication storage.
Some programs, such as Fresenius and Quality Dialysis, offer staff-assisted home dialysis. The nurse stays in the home and administers the dialysis treatment. Barclay said the service offers patients with tracheostomies or those on a ventilator an opportunity to leave the hospital. She indicated most dialysis centers will not accept patients with those needs.
Many nurses in the home dialysis programs enjoy the opportunity to teach and savor the satisfaction of watching their patients’ quality of life improve.
“I find it most gratifying,” MacFarlane said. “I see the results, and they are phenomenal.”
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