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Biomedical subjects

Jean L Holley

Publications and source records attributed to Jean L Holley.

14 recordsLinked to original sources
PubMed2006

Managing homeless dialysis patients.

Although our dialysis facility is located in a rural area, we noticed an increasing number of homeless patients requiring treatment. After researching the issue of homelessness in dialysis patients, we found little has been reported on the subject. We examined the characteristics of our homeless dialysis patients as well as the effects these patients have on the multidisciplinary dialysis care team. Six homeless patients were dialyzing in our in-center hemodialysis unit (monthly census averages 105-110 patients) in April 2005. All of the homeless patients were men; five of the six were African American, five had a history of substance abuse, and four a history of alcohol abuse. The mean age of these patients was 45.75 years, and the mean number of months on dialysis was 46.4. All were single (5 divorced, 1 never married), and 5 had a history of psychiatric illness. All six had Medicare coverage. The patients found shelter through local community shelters, the Salvation Army, and in their automobiles. The medical, nursing, dietary, and social aspects of the care provided by the dialysis multidisciplinary team members are discussed as it pertains to the care of homeless dialysis patients.

Adult↗
PubMed2006

Why all prescribed medications are not taken: results from a survey of chronic dialysis patients.

Although medication non adherence is common in all populations, including those on chronic dialysis, the reasons for medication noncompliance in dialysis patients have rarely been examined. We surveyed 54 chronic dialysis patients (15 on peritoneal dialysis, 39 on hemodialysis), asking about their social and financial situations, medication coverage, and reasons for possibly not obtaining all prescribed medications. The study population was 56% female, 52% African American, 67% over 50 years of age, 27% diabetic, and 61% on dialysis for more than 2 years. One patient was unemployed, 33 were retired, 15 were on disability, and 5 were employed. A majority (63%) had a household income of dollars 25,000 or more annually. Most (70%) had some medication coverage through one or more health plans (53% Medicare, 14% Medicaid, 31% private) or a local pharmacy (31% UVA pharmacy program for the medically indigent). However, 39% still spent more than dollars 100 monthly on medications. Co-pays per prescription ranged from nothing (2 patients) to dollars 25 or more (16 patients), with half having a co-pay of more than dollars 11 per prescription. Most (69%) took 11 or more medications daily. Among all our study patients, 91% reported that they knew their medications and the reasons that those medications were prescribed. The choice not to fill a prescription was made by 30% of patients either because they had no money (67%) or no ride to the pharmacy (17%). When asked if they ever chose not to take specific medications, 11 of 53 respondents (21%) said yes because of side effects [4 (36%)] or cost [3 (27%)], or because they already take too many medications [2 (18%)]. Most respondents (91%) reported discussing their medications with their doctors, and a majority (65%) had these discussions at least monthly. We conclude that inadequate prescription coverage, lack of transportation, and medication cost are primary contributors to medication noncompliance among chronic dialysis patients. Patients report knowing their medications and the reasons that those medications are prescribed, and having ample opportunities to discuss their medications with their physicians. Lack of patient education therefore does not seem to be an important factor in medication non adherence.

Aged↗
PubMed2006

A descriptive report of errors and adverse events in chronic hemodialysis units.

With the combination of technical equipment, medication administration, and caregiver-delivered treatment, opportunities for adverse events and medical errors exist in hemodialysis units. There are no studies describing the type and frequency of medical errors and adverse events in hemodialysis units. This study examines standard adverse events and medical errors reported on routine quality assurance forms by the clinical directors of four hemodialysis units between January 2004 and June 2005. The units varied in size (45 -108 patients), average number of hemodialysis treatments provided (524 -1,333/month), and staffing ratios (1:3 - 1:9.5). In total, 88 errors occurred in 64,541 dialysis treatments (1 event every 733 treatments). Infiltration of the hemodialysis access (n = 31 ) and clotting of the dialysis circuit (n = 19) were also fairly common while dialysis equipment problems occurred relatively rarely (30 occurrences in 64,541 treatments, or 1 event every 2,151 treatments). Thirty-five medication errors occurred (1 every 2,15 1 treatments); omission of an ordered medication was the most common (24/35, 69%). Nine patients fell and six of the falls occurred after a dialysis treatment. No patients required hospitalization as a result of the adverse events or errors. Errors and events were more common in the larger units but did not seem to be directly related to unit staffing ratios. Adverse events in hemodialysis units are fairly common and should be included among routine quality improvement issues addressed by dialysis providers and caregivers. More study of this issue is needed.

Documentation↗
PubMed2004

Palliative care.

Explore the source record for details and available documents.

Advance Care Planning↗
PubMed2004

The hypothalamic-pituitary axis in men and women with chronic kidney disease.

Although the precise abnormalities that lead to failure of the hypothalamic-pituitary-gonadal axis in men and women with chronic kidney disease (CKD) and end-stage renal disease (ESRD) remains undefined, evidence exists for defects in both the hypothalamus and the pituitary. The lack of appropriate cyclic release of gonadotropin-releasing hormone (GnRH) by the hypothalamus leads to loss of normal pulsatile luteinizing hormone (LH) release by the pituitary, which results in impaired ovulation in women and reduced testosterone and sperm production in men. The cause of impaired cyclic release of GnRH is unclear, but hyperprolactinemia, elevated endorphins, and high levels of GnRH and LH caused by reduced clearance may contribute. Perturbations of the hypothalamic-pituitary-gonadaotropin axis in CKD lead to high rates of infertility, dysfunctional uterine bleeding, and impaired puberty in children. Only through additional study of the complex effects of CKD on the hypothalamic-pituitary-gonadal axis will the precise abnormalities in hormonal control of reproduction be explained.

Chronic Disease↗
PubMed2003

The need for end-of-life care training in nephrology: national survey results of nephrology fellows.

Because of the high mortality rate of end-stage renal disease, nephrologists care for many dying patients. However, the education of nephrology fellows in palliative care has not been assessed. We surveyed second-year nephrology fellows to assess the quantity and quality of teaching they received in palliative medicine and also asked about their preparedness to manage patients at the end of life. A 63% survey response rate yielded 173 surveys for evaluation. Nearly all fellows (99%) agreed that physicians have a responsibility to help patients at the end of life; half thought it was very important to learn how to care for dying patients. On a 10-point scale in which 0 is no teaching and 10 is a lot of teaching, fellows reported significantly less teaching in end-of-life care (mean score, 3.8 +/- 2.6) than in managing a patient with distal renal tubular acidosis (mean score, 6.3 +/- 2.5) or on hemodialysis therapy (mean score, 8.9 +/- 1.5; all P < 0.0001). Specific palliative care content areas were taught infrequently; only 22% of fellows were taught how to tell a patient he or she is dying. Fellows who had contact with a palliative care specialist reported more education on end-of-life issues and believed they were better prepared to provide such care. Fellows' palliative care experiences during fellowship frequently occurred without attending nephrologist supervision; 32% of fellows had conducted 2 or fewer family meetings, and 26% of all family meetings occurred without an attending nephrologist. Fellows believed they were best prepared to manage a patient on hemodialysis therapy (mean score, 8.9 +/- 1) and least prepared to manage a patient at the end of life (mean score, 6.1 +/- 2; P < 0.0001). Our results show that most nephrology fellows believe they should learn how to care for dying patients, but most fellowship programs do not offer this training. Our study therefore suggests that training in palliative care be incorporated into fellowship program curricula.

Data Collection↗
PubMed2003

Advance care planning in elderly chronic dialysis patients.

Despite the usefulness of advance directives, most dialysis patients do not complete them. Current views of the advance care planning process emphasize that development of a specific written advance directive is only one small part of the process. Patients and families use advance care planning discussions to plan for death, achieve control over their health care, and strengthen relationships. Studies of chronic dialysis patients have shown that discussions about end-of-life care occur within the patient-family and not the patient-physician relationship. Successful advance care planning requires that dialysis care providers incorporate end-of-life care wishes and palliative care into the overall health care plans for their patients. This review focuses on the past impediments to achieving useful advance directives among dialysis patients and their families and provides some suggestions to improving this important aspect of dialysis patient care.

Advance Care Planning↗
PubMed2002

A single-center review of the death notification form: discontinuing dialysis before death is not a surrogate for withdrawal from dialysis.

BACKGROUND: Form 2746, the death notification form, is the primary source of data on cause of death for patients with end-stage renal disease in the United States. Since the revised form was introduced in May 1990, withdrawal from dialysis is no longer a specific cause of death code. A separate section of form 2746 asks whether dialysis was discontinued before death. Based on US Renal Data System data from form 2746, more than 20% of dialysis patients discontinue dialysis before death. It is not known whether stopping dialysis is a proximate cause of death in these patients. METHODS: Two hundred twelve death notification forms completed between January 1, 1993, and December 31, 2000, from a single dialysis center were reviewed for location of death, primary and secondary causes of death, and whether dialysis therapy was discontinued before death. Dialysis unit and hospital billing records of patients who discontinued dialysis before death were reviewed to obtain the dates of hospitalization and last dialysis treatment before death. RESULTS: Fifty-six patients (26%) discontinued dialysis therapy before death. In only 8 of those patients' deaths (8 of 212 deaths; 4% of all patient deaths), nephrologists used form 2746 to attribute the death to uremia from stopping dialysis therapy. Time in days from the last dialysis treatment to death in these 8 patients was longer than in the remaining 48 patients who stopped dialysis therapy before death, but in whom cause of death was not coded as uremia (median, 12.5 versus 5 days, respectively; P = 0.01). Patients who stopped dialysis therapy before death were more likely to have malignancy and less likely to have cardiovascular disease coded as cause of death. Most patients died in the hospital; only 2 patients died in hospice. CONCLUSION: There is physician variability in interpretation of discontinuation of dialysis before death. Thirty percent of patients who discontinued dialysis therapy before death died 3 or fewer days from their last dialysis treatment, making uremia an unlikely cause of death, but suggesting that nephrologists wanted to note that a decision not to continue dialysis therapy had been made before the patient died. Discontinuing dialysis therapy as noted on the death notification form is not a surrogate for withdrawal from dialysis as a cause of death. Providing criteria for reporting discontinuing dialysis therapy would allow us to clarify the incidence of withdrawal from dialysis as a cause of death.

Adult↗
PubMed2002

Enteral tube feeding in a cohort of chronic hemodialysis patients.

Malnutrition affects up to half of all chronic dialysis patients and is an important predictor of mortality, but the efficacy of interventions designed to improve the nutritional status of dialysis patients has been poorly studied. Specifically, although enteral tube feeding is often cited as an important option in the treatment of malnourished dialysis patients, there are few studies examining the effectiveness and complications of enteral tube feedings in adults on dialysis. We performed a retrospective analysis of a small cohort (n = 10) of chronic hemodialysis patients who received enteral tube feeding as all or part of their nutrition between January 1 and May 1, 1999, with follow-up through May 1, 2000, to assess the efficacy and complications of enteral tube feeding. Six patients received feeding via a peritoneoscopically placed (PEG) tube, 3 via nasogastric (NG) tube, and 1 patient was switched from PEG to NG feeding after an exit site infection developed at her PEG site. Seven patients received enteral feeding because of swallowing difficulties occurring after a cerebrovascular accident. Four patients were fed via enteral tube temporarily (</=4 months); the range of time on enteral feeding was 0.5 to 36 months. Five patients died by study end; only 1 recovered and no longer required enteral feeding. Patients were well dialyzed (median urea reduction rate, 73%). A significant improvement in serum albumin was seen (initial median albumin, 2.8, versus final median albumin, 3.4 g/dL, P =.04). Hypophosphatemia occurred in 8 of the 10 patients, and the nadir median phosphorus level was 1.95 mg/dL. One patient died as a result of an infected PEG. We conclude that enteral tube feeding is an important tool in the treatment of malnourished chronic hemodialysis patients and deserves formal study. Hypophosphatemia commonly occurs, and phosphorus levels should therefore be followed closely when initiating tube feedings in hemodialysis patients. In some cases, a nonrenal enteral formula may be useful for avoiding hypophosphatemia in these patients.

Adult↗
PubMedDate not supplied

Cardiopulmonary resuscitation and dialysis: outcome and patients' views.

Cardiopulmonary resuscitation (CPR) was initially described as an intervention to be used in otherwise healthy individuals suffering acute cardiorespiratory arrest. Over the years, CPR has been extended to all hospitalized patients unless specific orders not to resuscitate have been written with the informed consent of the patient and/or surrogate. The 14-15% survival to hospital discharge reported for in-hospital CPR has not changed over the past three decades. Compared with other diseases, chronic kidney disease reduces long-term survival (more than 6 months) following CPR, and the functional status of the few who survive is often quite poor. Nevertheless, most dialysis patients want to be resuscitated. Unfortunately television shows portraying resuscitation imply that survival after CPR is much more common than it really is. Such misinformation contributes to the overwhelming choice for CPR despite the dismal prognosis. Dialysis unit staff need to educate patients and families about the expected success and complications of CPR as part of the advance care planning process that should now be routine.

Cardiopulmonary Resuscitation↗
PubMedDate not supplied

Pregnancy in dialysis patients: a review of outcomes, complications, and management.

Although uncommon, pregnancy occurs in women on chronic dialysis. In 1980 the incidence of pregnancy in women on dialysis was 0.9%. Studies from 1992 to 2003 indicate that pregnancy occurred in 1-7% of women on chronic dialysis. Half of the infants born to women on chronic dialysis survive. Of importance is that "intensive dialysis" of 16-24 hr/week is associated with improved infant survival. In this article, the incidence, duration, fetal and maternal complications, and outcomes of pregnancy in women on chronic dialysis are reviewed. The management of anemia, hypertension, electrolytes, bone minerals, and acid-base parameters in the pregnant dialysis patient is also summarized. Recommendations regarding the dialysis prescription for the pregnant woman on hemodialysis (HD) or peritoneal dialysis (PD) are also made. The complex and precarious condition of the pregnant woman on dialysis requires close collaboration between the patient, nephrologist, dialysis staff, obstetrician, and neonatologist to maximize the chance of a successful pregnancy.

Female↗
PubMedDate not supplied

Palliative care in end-stage renal disease: focus on advance care planning, hospice referral, and bereavement.

The components of palliative care in end-stage renal disease (ESRD) include pain and symptom management, advance care planning, psychosocial and spiritual support, and ethical issues in dialysis. End-of-life care is not synonymous with, but rather a subset of palliative care. Advance care planning occurs within the patient-family relationship and is a dynamic process that prepares for death, strengthens interpersonal relationships, and allows a patient to achieve control over his or her life. It is incumbent upon dialysis care providers to include advance care planning in overall care plans for their patients. Factors contributing to the failure of advance care planning in ESRD patients will be discussed, as will hospice and ESRD, and opportunities for bereavement programs.

Advance Care Planning↗