Answer: Certainly not by covering one's head and falling asleep and trying to shut out the world of the dialysis unit. Alert patients have a number of legitimate concerns about safety in the dialysis unit.  Many of these concerns revolve around the sufficient number and experience of the personnel caring for patients in the unit. Patient to (on-the-floor) staff ratios have continued to rise, mostly as a result of rising costs, limits on reimbursement and the desire by the owners of the unit to make a profit. Optimal ratios would be three patients to one staff member (nurse or technician), but the ratio has risen to four to one or possibly even higher. Patients are worried that too few or too inexperienced staff members may not have time to be attentive to safety concerns and other patient needs, such as medications or familiarity with the dialysis machines or clean and proper needle insertion. Proper functioning of the dialysis machines is another concern. Frequent equipment breakdown can be frightening. Problems with losing the fluid gained to dry weight can leave one at risk for pulmonary edema and heart failure before the next treatment. In short, in some situations, dialysis patients might receive treatment while being in fear for their lives.

The departure of comfortably familiar staff members for other jobs and arrival of new and often inexperienced staff members can also cause severe unease for patients. In many units, frequent turnover among staff is a fact of life.  The ever-growing number of dialysis patients leads to a greater need for new caregivers, many of whom will not have had previous experience in the field. What can be done about this?  Training programs and certification for dialysis nurses and technicians have been recommended. While the professional organizations of dialysis nurses and technicians have written programs and offer regular educational meetings, most states do not require reading of the manuals and attendance at these meetings. Only a few requirements exist to become a patient care technician in a dialysis unit.

Is there another, albeit temporary, solution while waiting for the regulatory authorities to take action?  I urge that all capable patients become more involved in their dialysis care. It is obvious that patients with diabetes, high blood pressure or other chronic illnesses should feel better and have superior results when fully participating in the management of their medical condition. This is especially true for the dialysis patient. It would seem natural for patients who will depend on a dialysis machine for the rest of their lives to want to know how it works. Make sure the ordered blood flow is set (for dialysis adequacy) and the settings to remove the fluid gained are correct.  See if your venous or arterial pressures have changed with each treatment as an indication of problems with your access. When alarms go off, learn what they mean. If the staff precludes you from participating in your care, including observation of the machine, you should ask why.  Also, familiarity with the machine eases safety concerns related to the treatment during times when  the unit is shorthanded or staff members are new. (Patients can learn more about their care by reading the AAKP Patient Plan©.)

Many dialysis patients experience a great deal of relief when they learn how to insert their own needles. Missed needle punctures, sometimes leading to the loss of a blood access, are a major trauma for the dialysis patient. When somebody else puts in your needles, you can never be certain that even the best stickers will find the proper area for insertion. Putting in your own needles, on the other hand, is the best guarantee for a sure stick and with less pain. For me, knowing I have a spot to dialyze and a reliable machine is all I need to approach my dialysis treatments with minimal anxiety.

It is true that many patients are too old or feeble to have any involvement with their dialysis treatments. However, for those who can, greater personal participation in one's care will allow the available staff to better tend to those who are unable to participate. Covering one's head with a blanket or yelling at the unfairness of it all will not soothe one's concerns, a greater attention to what is happening during your treatment will.

P.S. If your unit says you cannot be more involved in your care, find one that says you can.

Answer provided by A. Peter Lundin, MD. Dr. Lundin is a nephrologist at the State University of New York, Health Science Center in Brooklyn. He is a past president of AAKP and a member of the AAKP Medical Advisory Board. 

The Dear Doctor column provides readers with an opportunity to submit renal related health questions to healthcare professionals who specialize in the area of concern. The answers are not to be construed as a diagnosis and therefore, altercations in current healthcare should not occur until the patient's physician is consulted.

This article originally appeared in aakpRENALIFE, Volume 16 Number 4, January 2001.

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