Quality of life in patients with renal failure

Quality of Life and the Patient With Renal Failure

Quality of life

The patient in this case study is known as Mrs. E.S. She was admitted to the Renal Medicine Unit on the September 25, 2009, after a diagnosis of renal failure. The patient was born on the 31st of July 1922. Her weight at the time of admission was 77.270kg. Her height is 162.6cm. Her prior medical history includes breast cancer thirty years ago, which resulted in a hysterectomy of the left breast. Other relevant medical aspects include stents to the heart (2005), hypertension, gout, and arthritis of hands and legs, a cataract removed in both eyes and TIA. Currently, she is undergoing hemodialysis three times a week. Allergies include Penicillin and CT dye, but she has no food allergies.

In terms of family background, relatives and caregiving, her husband is the major caregiver and they both live in the same house. She also has a daughter, son and four grandchildren and they live outside her own city (Mississauga). They visit once a month but still keep in touch by calling twice daily.

Mrs E.S. is aware of and understands her diagnosis. In terms of independence and dependency factors she is dependent and finds self-care problematic.

1. Introduction

Simplistically stated, renal failure is essentially a serious medical condition affecting the kidneys which do not function adequately. This failure can be "…a progressive disease or a temporary one depending on the cause and available treatment options" (What is Renal Failure?) One has to distinguish between acute and chronic renal failure. Acute renal failure is described as the "… sudden loss of the ability of the kidneys to remove waste and concentrate urine without losing electrolytes" (Acute kidney failure). Chronic renal failure is a condition that typically develops over a number of years as a result of the progressive damage to the internal structure of the Kidneys. Symptoms of renal failure in this case often are hidden and are not obvious until kidney function is less than one-tenth of normal (Acute kidney failure).

Unlike acute failure, chronic renal failure becomes progressively worse over time and can range from mild kidney dysfunctionality to severe kidney failure -- which is the case in the patient under discussion. This condition may also lead to end-stage renal disease or ESRD.

As is the case with Mrs. E.S., renal failure is often diagnosed in its chronic phase in older patients. The literature points out that this fact is has only recently been established through research (Beeson et al., 2009, p 245). Importantly from a nursing and healthcare perspective, this disease also has a number of comorbid implications. These include, among others, the following, "Increased cardiovascular risk, secondary complications such as renal anemia and bone disease and a small but significant risk of progression to established renal failure ( ERF)" (Beeson et al., 2009, p. 245). As will be discussed, these aspects also refer and relate to the important issue of quality of life. This also refers to psychological as well as socio-psychological aspects that play a significant role in the management and treatment of these patients.

Related to the above is the research finding that; "Chronic kidney disease or CKD is becoming increasingly common. The United States Renal Data System has reliably estimated that the number of patients on maintenance dialysis in the United States will double over the next few year"(Locatelli and Pozzoni, 2006, p. 2118). This applies particularly to the elderly: "The increased incidence of CKD among the elderly translates into a similarly increased prevalence" (Locatelli and Pozzoni, 2006, p. 2118). The Third National Health and Nutrition Examination Survey (NHANES III) of a nationally representative sample of adults in the United States between 1988 and 1994 found that, "7.6% of the individuals aged 60 -- 69 years, and 25.9% of those aged at least 75 years, had a glomerular filtration rate (GFR) of 15 -- 60 ml per minute per 1.73 m2, as against only 1.8% of those aged 40 -- 59 years and 0.2% of those aged less than 40 years (Locatelli and Pozzoni, 2006, p. 2118/9).

With regard to general treatment, dialysis patients require a "constraining" regime of protocols and care; which includes regular hospital for treatment and ongoing monitoring (Tyrrell et al., 2005, p. 374). It also a significant to note that since the inception of treatment for this condition by means of dialysis there have been an increasing number of older people who have undergone this intervention; for example, "… in 1991, 18,000 patients received dialysis and only 5.5% of them were more than 80 years old; three years later, about 20,000 patients underwent dialysis procedures and 10% of these were more than 80 years old…" ( Tyrrell et al., 2005, p. 375).

As a result this has become a relatively common treatment for older patients and the outcome in terms of recovery has also improved ( Tyrrell et al., 2005, p. 375). However, the focus of this paper will be on the quality of life associated with various interventions and the way that the patient and family are affected and cope with this condition.

2. Background

The patient in this study has a long history of ailments and illness. The overall health and psychological as well as existential perceptions and outlook of the patient have to be taken into account. Her situation in terms of quality of life is compounded by the dialysis treatment, and this in turn has a number of important effects and consequences. These have to be considered in the light of management and coping strategies as well as in treatment protocols. Central to this analysis is the impact on the family and immediate caregivers.

2.1. The impact on family

A very insightful study into the affect on the family and the spouse of the patient undergoing dialysis is by Ziegert et al. (2006). "When a patient is stricken by a chronic disease, his/her everyday life changes as do the lives of his/her spouse and other family members who are emotionally and socially close to the patient " (Ziegert et al., 2006, p.223). This article goes on to outline the type of demands made on family members. The authors note that, " Despite the fact that haemodialysis demands that next of kin support and assist the patient during the treatment period, little attention has been focused on their own health in this situation" (Ziegert et al.,2006, p.223).

The point being made is that the spouse or the immediate caregiver has to endure a great deal of uncertainty within their own lives as a result of the demands of the dialysis treatment. This can lead to various negative outcomes, for example, "the uncertainty in relation to the patient's health leads to resignation in everyday life. It is also well-known that next of kin of patients on haemodialysis can suffer from fatigue and depressed mood as well as guilt and hopelessness (Ziegert et al.,2006, p.223).

Not only does this article suggest that dialysis places a great deal of stress on the spouse but it also adds to the responsibility that he or she might feel as they have to maintain a supportive role.

This aspect will be explored in more detail as it relates particularly to the question of quality of life. This refers as well to the overall quality of life that is a combination of the patient, her family and living environment. As noted, the patient in question in this study is supported almost entirely by her husband. Both are elderly and the fact that she has to rely on her husband has created areas of anxiety in her life, which has compounded and exacerbated the difficulties of treatment. As Ziegert points out, "…the care for and worry about the patient can lead to the relationship between the spouses becoming complicated and fraught with responsibility, a situation that can become strenuous for both of them (Ziegert et al. 2006, p. 227).

This is an important point and one that will be pursued in terms of theories of existential and holistic care that should guide nursing protocol. Furthermore, this perspective or trajectory of thought has in turn necessitated a more cautious and psychologically sensitive approach in terms of management and treatment protocols. As will be elaborated on, an area that is lacking in much of the literature or which could be better understood and implemented is the spiritual or religious dimension of treatment as it pertains to improving quality of life.

3. Overview of the relevant literature

Some aspects of the nursing literature pertinent to this case have been referred to above. However, there are a number of other aspects in terms of the issues and challenges that face the patient and family experiencing a complex health challenge. This also relates to the topic of quality of life. Tyrrell et al. (2005) discuss the definition and assessment of the quality of life. This refers to a combination of medical, sociological and psychological factors that contribute to the meaning of this term. It is also important to distinguish between the subjective or personal view of quality of life and the professional's objective evaluation of the health status of individuals (Tyrrell et al., 2005, p. 375).

With regard to the patient's quality of life and treatment the above study notes that; "We have observed that some older dialysis patients experience considerable difficulties with this treatment regime. Apart from physical discomfort, some patients have difficulty complying with treatment, or repeatedly express the wish to give up dialysis" (Tyrrell et al., 2005, p. 375). These and other problems emphasize the fact that the treatment regime can be arduous for elderly patients and, if not in administered and managed correctly by the nurse or caregiver, can radically decrease the quality of life of the patient and his or her family.

Another issue that is reiterated in the literature is the degree to which the elderly patient understands the treatment. This is an area where the philosophy of care and the holistic approach to nursing praxis comes into play; and where the nurse can help in the process of explanation and understanding. Related to this are the various psychological issues that can inhibit the treatment process. These may have a significant effect on the quality of life but as Tyrrell et al. note they "… are not routinely assessed in dialysis patients" ( Tyrrell et al., 2005, p. 375).

Therefore, the purpose of the above study was to evaluate levels of cognitive impairment, depressive mood and self-reported quality of life in older dialysis patients. A total of 51 outpatients receiving dialysis were assessed with, among others, a quality of life questionnaire (NHP). It was found that, "Sixty percent of the patients were depressed, and between 30 -- 47% had cognitive impairment. Almost half of the depressed patients were also cognitively impaired" (Tyrrell et al., 2005, p. 374). The study therefore suggests that "Regular assessments of depressive mood, cognitive ability and quality of life are recommended, given the prevalence of problems in these domains for older dialysis patients" (Tyrrell et al., 2005, p. 374). This study and others also note the relative paucity of research into the area of emotional well-being and its importance in the treatment of these patients. For example, "…Kimmel et al. (1998) also found that rates of hospitalization for dementia and organic disorders were "…much higher in patients with chronic renal failure, compared with those suffering other chronic diseases" (Tyrrell et al., 2005, p. 375).

In terms of the central focus of this paper, studies such as Renal dialysis abatement: lessons from a social study (2005) by Ashby et al. investigates"… the reasons why some people chose to abate & #8230; renal dialysis, together with the personal and social impact of this decision on the person concerned, and/or their families" (Ashby et al., 2005, p. 389). Significantly it was found that, "The desire not to burden others and the personal experience of a deteriorating quality of life were crucial elements in the decision to stop or decline dialysis" ( Ahsby et al., 2005, p. 389). Ashby et al. also note that cultural and language factors as well as communication play a role in ascertaining the quality of life of these patients.

Importantly, a number of studies stress that the quality of life should also be considered from an experiential and existential point-of-view. This has a bearing as well on the nursing management of these patients and is an aspect that has been relatively neglected in contemporary treatment. For example, Ashby at al.( 2005) state that some elderly patients withdraw from dialysis treatment as a result of difficultly in discussing their fears and doubts with medical staff and family. Some have deep religious convictions that they feel are not appropriate to share in a medical and nursing context. This means that a more inclusive and interpersonal methodology is necessary in many cases.

This also relates to the issue of faith and religious perceptions in the treatment process. Studies such as Faith by James Dette ( 2008) emphasize the importance of this dimension and its relationship to a more integrated and holistic approach. An article entitled Developing a renal supportive care team from the voices of patients, families, and palliative care staff ( 2008) explores the concept of a Renal Supportive Care Team, which is "… designed to elicit and provide for the needs of dialysis patients and their families throughout the trajectory of their illnesses"( Berzoff and Swantkowski, 2008, p.133). The results of this study provide insight into the more integrated and humanistic approach which is the central focus of this paper.

Respondents agreed that there needed to be greater education of both patients and families regarding all aspects of the disease process, open communication, on-going support between patients, families, and the staff, continuity of care, pain control, and assistance with advance care planning ( Berzoff and Swantkowski, 2008, p.133).

This leads to nursing theories such as the Theory of Human Caring propounded by Jean Watson, which will be referred to in the following section.

4. Identification of gaps, implications for nursing practice and evidence-based recommendations

From the above brief overview of the literature it is clear that there are a number of pertinent and essential issues that are of significance in dealing with these patients. This also applies to the particular patient under discussion. These include issues such as cognitive impairment, psycho-social aspects and communicative aspects that relate to the question of quality of life; for example, "…the presence of unrecognized psychopathology can complicate the management of this patient group" (Tyrrell et al., 2005, p. 378).

Therefore, best treatment practices include the routine screening of these patients in order to determine whether there are cognitive impairments or signs of depression. In other words, "The health-related quality of life of elderly dialysis patients also needs to be monitored, preferably using self-report measures such as the NHP, and semistructured interviews" (Tyrrell et al., 2005, p. 378).

In terms of quality of life the issue of good communication is imperative, as well as positive relationship factors. This applies to the relationship between the patient and medical staff as well as family. In this regard the implementation of a Renal Supportive Care Team is a very useful method of ensuring that quality of life is optimized for the patient. This is an aspect that relates particularly to the patient in this case study.

However, as has been suggested in the above review, the area of existential and religious perceptions that have been relatively neglected. To this end I would suggest the theories such as Jean Watson's Theory of Human Care should be implemented in this case.