Thursday, April 22, 2010

Bad patient or bad process?

Dr. John Agar, a firm believer in the benefits of more frequent, longer dialysis posted in response to a thread on the Home Dialysis Central forums about 'non compliant' patients. Dr. Agar hits the nail on the head when he says, "It is much easier to blame the patient for non-compliance than to grapple with the concept that the treatment that is being delivered may be inadequate, too short, too 'bazooka', too blunderbuss, too brutal ... or just wrong."

For years, the medical team has blamed the patients for things that are beyond their control. Patients do not come back fluid overloaded because they like to do it. They are not out to trouble their medical team. They do not enjoy being breathless!

The inadequacy of their treatment and the far from optimal dialysis that they got in the last session causes insatiable thirst. Thirst, as Dr. Agar so rightly puts it is "is a primal, irresistible primitive survival mechanism for all living organisms".

... the acute volume contraction of 'bazooka dialysis' (fast, hard, unsympathetic, short-hour, low frequency dialysis) results in a raging thirst.

… again - remember - thirst is a primal, irresistible, basic instinct. None of us can resist it ... when activated, it is all-consuming!

… and so, at the end of the all-too-short dialysis, the intravascular volume having been tightly contracted, the patient is discharged home (usually with a parting admonition at the door) with a raging thirst and their primal, irresistible survival mechanism fully switched on.

… surprise, surprise ... the patient drinks excessive fluid! Who wouldn't? I would! You would! Thirst is a mechanism that preserves the organism. Few (if any) can resist it!

… and, fearful and guarded now of the next 'berating', the patient fronts up for the next dialysis - too heavy, too much fluid on-board, too much weight gain - but, never having stood a chance!

… at the door, to greet, an angry yet poorly understanding dialysis professional

... another berating, another session of angst, anger, resentment, distrust.

… and ... what happens? Another short dialysis with an even higher UFR

... and yet another irresistible thirst cycle is switched on.

Dr. Agar has years of experience, a lot of it with patients on nocturnal dialysis. He is an untiring advocate for longer, more frequent dialysis. His genuine concern for patient well being is truly amazing. Despite his extremely busy hours, he somehow makes time to answer questions on this forum.

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