Standards of care in practice: the nurse's role in effecting change.

Elderly patients on dialysis present a special challenge because they are often unsure of taking their health into their own hands and may be more resistant to self-management. When G.B. started on dialysis, he had little knowledge of what this entailed and self-management was not a concept that he could accept. Assertive communication with caregivers and protective self-management strategies were stressed as he transitioned to the unit. He did not complain to his providers when cannulation became more difficult, perhaps because of what he perceived as negative repercussions (Curtin, Sitter, Schatell, & Chewning, 2004). Reassurance, presence, and explanations were helpful in alleviating G.B.'s fears of speaking up. Communication was critical and required an ongoing effort by the staff. End of life issues common to the elderly patient include establishing an advance directive. G.B. chose a do not resuscitate status. He discussed his wishes with the social worker and though he did not want heroic efforts if he was at his home, he wanted reasonable measures done while at the dialysis center. Therefore, he decided that full resuscitative measures should be instituted. He was not a candidate for transplantation. G.B. presents with many issues familiar to dialysis nurses. On going and ever-changing planning is needed for the patient undergoing any extracorporeal treatment. As the primary contact with the patient the nurse is also the primary communicator with the physician who rounds in the dialysis unit. In addition, problem identification and initiation of referrals makes the nurse the most important connection for the patient on dialysis. This case uses the recently revised standards of care for nephrology nursing and the KDOQI guidelines. The standards support the creativity and decision making needed for individual patients in planning of care (Amato, 2006; Burrows-Hudson & Prowant, 2005) and the KDOQI guidelines substantiate interventions used in caring for G.B. Interpretation of the guidelines for individual patients and families is an important step. Problems for the elderly as they undergo hemodialysis require ongoing assessment and evaluation in order to bridge care from dialysis to end of life. Each of the guidelines offers just that, a guideline for the stages and experiences of the patient on dialysis.