First 90 to 120 Days on Dialysis: Importance of an Orientation

Patients with end stage renal disease (ESRD) can experience many challenges during the first 90 to 120 days on dialysis. There are many critical touchpoints and opportunities for kidney professionals to help them navigate this vulnerable time, during which patients may be anxious, confused, and even depressed—while simultaneously dealing with effects of uremia and general poor health. The dialysis interdisciplinary team has many goals to accomplish for these patients, including:

• Assessing current support systems, general coping ability, and emotional, mental, and physical health (historical and at the present time)
• Assessing patient vocational goals, plans and ability or interest in engaging in vocational and work activities
• Educating on transplant and modality options
• Discussing advance care planning, including health care proxy, living wills and do-not-resuscitate

Many patients, before beginning the dialysis journey, are followed by a nephrologist, receive education and support, and make preparations before initiating dialysis. These folks tend to experience better overall adjustment to dialysis, are more likely to have a permanent access placed before dialysis and are more likely to choose home dialysis as their treatment modality. In some instances, they may even be able to prolong the need to begin dialysis as a result of receiving chronic kidney disease (CKD) education and support (which sometimes includes diet, lifestyle and medication changes).

Regardless of whether CKD education and support were provided to patients prior to dialysis, it is helpful to have a period of orientation in the first 90 to 120 days to promote better adjustment. Nephrologists can look at this orientation class as a mandatory appointment, much like a pre-op appointment. This new-patient orientation could include any or all of the following:

• Patients meet with a care team member in the dialysis center before their first treatment. They could be taken on a tour and exposed to the dialysis milieu (including the sounds of alarms). This tour can also include an overview of how a typical treatment works, what to wear and what to bring.
• During this time, the care team member can address patients’ questions, fears and concerns 1:1 before they are exposed to the dialysis treatment floor on their first day of treatment.
• Time-sensitive topics—such as treatment adherence, the benefits of remaining vocationally active and ways to adjust to life on dialysis and stay healthy—can be addressed proactively to set a positive tone from the outset.
• It may be necessary to return to certain topics during the first 90 to 120 days as it may take time for the patient to fully comprehend all that is being shared and it also gives an opportunity for their renal function and overall health to stabilize.

To ensure the orientation is appealing to the full range of adult learning styles, dialysis providers can provide this new patient education in a variety of ways, such as providing videos or handouts or even including other patient mentors in the education process. It could be helpful to use a teach-back method during the education to verify the patient is fully comprehending what is being taught and to offer ample opportunity for questions, answers and reassurance. Also, it would be very helpful to include someone from the patient’s support system (e.g., family, friends) who could help reinforce learnings and solidify that the patient is not alone in this process.

By engaging patients in this orientation and education process during the first 90 to 120 days on dialysis, the patient-centered approach is fully realized. Bite-size pieces of information can be shared and patients, allowing them time to make decisions and be active participants in their own care planning.