Thursday, 19 July 2007

Twice weekly haemodialysis - what would your advice be?

Historically, many centres have temporarily coped with capacity constraints by starting patients new to haemodialysis on twice weekly regimes or even reducing those with some residual function from thrice weekly sessions. In the past decade this has become a less frequently used option in all but a few centres. At the dialysis summit I was asked what my advice woud be to a Clinical Director contemplating such a strategy because of demand outstripping capacity. The scenario is already being discussed in dialysis units. In many place, perhaps most, the plants for additional haemodialysis capacity beyond 2008 are not yet concrete. A simple "I wouldn't contemplate it" ducks the issue. But these capacity crises do not occur overnight. The haemodialysis programme has to be seen in the context of the whole service - when it's at full stretch and we are juggling spaces it's difficult to stand back and try to optimise other aspects of end stage renal disease management.

Paradoxically, undue pressure on maintenance haemodialysis services diverts resources and attention from preparation and planning, home therapies and supportive and palliative care - each of which in their own way when delivered efficiently can reduce the demand on maintenance haemodialysis.

My response was that, in all but exceptional circumstances, twice weekly haemodialysis is inadequate - I believe that it is a patient safety issue; a blanket policy to arbitrarily start or reduce patients to twice weekly dialysis is indefensible. If some patients were to be "offered" twice weekly haemodialysis they need to be very carefully selected, residual renal function and dialysis adequacy needs close monitoring. Patients should be fully informed in writing of the rationale and risks of twice weekly dialysis. The triggers for a move to thrice weekly maintenance haemodialysis should be explicit and agreed with the patients at the outset.

If a systematic strategy is being contemplated because of either short term, eg unexpected and severe nursing shortages; or long term planning failure, not only clinicians but also management (and I would suggest the Chief Executive Officer as the most appropriate management colleague, who, with the consultants will carry the medico-legal risk), commissioners, SHA colleagues (who have a performance managment role for the system) and patient representatives should be involved in the discussions and decision making processes. The National Kidney Federation Advocacy officers now sit on many network groups and are a persuasive force for patient interests. Negotiating with patients in one room keeps the clinician and managerial focus on the task in hand - the quality of services. The discussions should not occur just between doctors and indeed should not occur without considering the broader context, investment and options available.

Twice weekly haemodialysis is not part of a world class quality service and we should not tolerate it - it is an issue I have raised at Strategic Health Authority and commissioning level in several parts of the country. If such a scenario is being contemplated in your unit or network please let me know - my role involves offering assistance in such circumstances.