FINANCIAL & PSYCHOSOCIAL PROBLEMS OF PATIENTS UNDERGOING

DIALYSIS

CHAPTER I

INTRODUCTION AND BACKGROUND OF THE STUDY

I. INTRODUCTION

End Stage Renal Disease is a highly prevalent and rapidly increasing

condition. Thus, Dialysis is the lifesaving treatment for those with ESRD. And

persons over 65 years of age are soon expected to make up majority of those

requiring maintenance dialysis therapies. Each year an estimated 120 Filipinos

per million population (PMP) develop kidney failure according to the Philippines

Disease Registry. This means that about 10,000 Filipinos need to replace their

kidney function every year. In 2007, only 7,267 patients were able to start dialysis
or received kidney transplant directly. Only 73% received treatment because they

can afford the dialysis or the transplant.

According to the Philippine Disease Registry’s annual report the leading

cause of kidney failure in the Philippines is DM (41%) on 2008, followed by

inflammation of the kidneys (24%) and high blood pressure (22%). Patients were

predominantly male (57%) with a mean age of 53 years old. Patients undergoing

this treatment are Financially, Psychologically & Financially affected.

Financially because an adequate dialysis costs from P 25,000 to P 46,000

per month or P 300,000 to P 552,000 annually. If one is able to afford this

treatment then the patient will be well enough to return to his normal way of life,

and just apportion time for dialysis treatment. However, majority of the Filipinos

can’t afford this costly treatment for more than a year. A study at the National

Kidney & Transplant Institute (NKTI), a tertiary government providing services for
kidney disease, showed that half of the patients who start dialysis are dead within

a year, presumably because they could not afford sufficient dialysis. Most

patients pay their treatment without subsidy from the insurance. Philhealth covers

51% of the annual cost of treatment, if the maximum benefit is claimed. The

patient needs to pay half of the treatment or at least P 150,000 per year.

Patients without sufficient dialysis are weak and display many symptoms

that led to their diagnosis. They are malnourished and unable to work, existing

only until the next dialysis treatment, whenever it may be.

They are psychologically affected because they see themselves as

burden to their families. Most of the dialysis patients have worries about their

ability in managing their treatment. A caregiver or family member should is

needed to care for the patient, attends to medication & meals & assist in

providing treatment. Commonly, some family members stop working to care for
the dialysis patient. The patient is too weak to provide self-care & loses

independence.

II. STATEMENT OF THE PROBLEM

This study aims to assess the level experienced by patients

underoing dialysis and identify what are the greatly factors affect the patient. The

results of this study will primarily be useful for the people who regularly visit

dialysis centers for atleast 3 times a week.

Sub-Problems:

What is the Socio-demographic profile of the clients/respondents as to:

1.

Age
1.1

1.2 gender

civil status
1.3

1.4 annual family income

 1.5 length of time undergoing treatment

2. What are the problems experienced by the patients undergoing dialysis

terms of:

2.1 financial

2.2 social

2.3 psychological

III. CONCEPTUAL FRAMEWORK

Input

Process Output
financial
Assess of level Respondent’s

experienced related to perception or

social decision in
financial, social and
continuing the
psychological
psychological treatment of their
of patient who
sick members to
undergoes the
the dialysis center.
treatment.
Schematic Diagram of the Study.

The demographic characteristics may affect factors of perception the

respondent along the different factors related to financial, social and

psychological. Financial factors may affect the respondent’s perception or

decision in receiving or not receiving dialysis in dialysis centers because for

some families the treatment cost may be too expensive to maintain. The social

factor also has a relation because dialysis patients are confined on limited

activities. Another factor that affects the perception of the respondents is

psychological factor because patients who undergo a lifetime treatment tend to

have mental suffering due to distressing outlook of life knowing that he or she will

be receiving dialysis for life unless he or she receive an healthy organ.

IV. SIGNIFICANCE OF THE STUDY

The research of the study are very important because it will lead to

the awareness of the healthcare professional towards the needs of family and

patients undergoing dialysis. In study, the findings aim to determine the greatly

factors and helps to increase the understanding towards the problems. Thus, the

following sectors would also benefit such as:

The results of this study will primarily be useful for the people who

who regularly visit dialysis center for atleast 3 times a week.

Disease clients
 Clients with Alzheimer’s disease will benefit a lot from this program

because we will be able to develop a support program for their family caregivers

that will lead to the improvement of the caregiving activities rendered to them.

Family Caregivers

As the main focus of study, family caregiver will benefit a lot from this

study because the burdens that they experienced will be identified and a support

program will be develop. Thus, proper attention and group support will be given

to them.

Nursing administrators

To see the results and findings of the study as a basis on developing a

support program for the patients and family care givers of the patients who

undergo dialysis.

Other Health Workers

The result of the study will give other health care team a better

understanding of family caregivers and their needs thus, promoting a favorable

environment to lessen their burden.

Institutions/Associations

An insight will be provided by the study for the institutions/associations to

create a group and develop a support program thus promote information

dissemination of the people.

Future Researchers
 This study can serve as a guideline data on the economical and psycho-

social burdens experience by the clients who undergo dialysis; and the needs of

the health care provider to include the family caregivers in the holistic care of the

patient.

Patients Undergoing Dialysis:

Patients who are undergoing Dialysis will benefit a lot from this research

because they will be able to determine what are the factors and help them cope

through out the treatment. & will help them encourage to continue the treatment

while waiting for organ donors.

V. SCOPE & LIMITATION

This study is focused to assess the financial & psychosocial problems of

patients who are undergoing Dialysis. The respondents are composed of 20-40

dialysis patients could be male or female from Capitol Medical Center.

VI. DEFINITION OF TERMS

Operational Definitions:

Burden - an onerous or difficult concern, it’s either financial or emotional

experiences.

Dialysis - is a procedure or treatment for patients with End Stage Renal Disease.

ESRD – End Stage of Renal Disease where dialysis is necessary.

Psychosocial- refers to the psychological development & interaction in the

society.

Financial – refers to money; the expenses given to compensate maximum

effectiveness of treatment; necessity of life

Diabetes Mellitus – most prevalent disease costing kidney failure that eventually

needs dialysis.

Patients – Program a series of steps to be carried out or goals to be

accomplished.

Social - relating to human society and it’s members.

Support Program - a process to be carried out or goals to be to provide or

maintain by supplying with money or necessities.

CHAPTER II

RELATED LITERATURE
 Each year an estimated 120 Filipinos per million population (PMP)

develop kidney failure. This means that about 10,000 Filipinos need to replace

their kidney function each year.

Sadly, in 2007 only 7,267 patients started dialysis or received a kidney

transplant directly. Only 73% received treatment because they were able to get

to a hospital providing dialysis or could afford the therapy. The acceptance rate

of treatment for kidney failure in the Philippines is only 86 PMP, compared to 100

PMP in South Korea, and 300 PMP in the United States (accessed from the

International Federation of Renal Registries in 2000 Web site). A quarter of

Filipino patients probably just died without receiving any treatment last year.

The leading cause of kidney failure in the Philippines is diabetes (41%),

according to the Philippine Renal Disease Registry Annual Report in 2008,

followed by an inflammation of the kidneys (24%) and high blood pressure (22%).

Patients were predominantly male (57%) with a mean age of 53 years.

Thus, diabetic males in the most productive years of their lives comprise

the population who received treatment for kidney failure in 2007. They require

replacement of their kidney function to live. Without dialysis or kidney

transplantation, patients with kidney failure die.

Options for treating kidney failure

Patients developing kidney failure can choose between dialysis and

kidney transplantation as treatment for their illness. Dialysis comes in the form of

hemodialysis (HD) where the patient’s blood is made to run through a series of
tubes which removes poisons and excess fluid that have accumulated in the

blood, and is then returned to the patient. A hemodialysis session lasts for four

hours and needs to be done three times a week to adequately replace sufficient

kidney function for the patient to live. The patient needs to travel to a dialysis unit

each time for treatment.

Another option is peritoneal dialysis (PD), where a permanent tube is

placed in the patient’s abdomen, and the patient’s own membrane acts as the

artificial kidney. Special fluid enters the abdominal cavity and stays there for

several hours, and the poisons and excess fluid transfer from the blood to the

fluid, which is drained out of the body. This process is done daily, three to four

times a day. Patients are trained to perform this type of therapy by themselves at

home.

The best way to replace kidney function though is to transplant another

kidney into the patient through a surgical procedure. Only another kidney can

completely replace kidneys shrunken because of disease. Dialysis only provides

about 15% of kidney function. It is enough to sustain life, but needs to be

performed regularly, and for life.

Cost of treatment

Adequate dialysis costs from P25,000 to P46,000 per month or P300,000

to P552,000 annually. If one is able to afford this lifelong treatment then the

patient will be well enough to return to his normal way of life, and just apportion

time for dialysis treatment. However majority of Filipinos cannot afford this costly

treatment for more than a year. A study at the National Kidney and Transplant
Institute (NKTI), a tertiary government hospital providing services for kidney

disease, showed that half the patients who start dialysis are dead within a year,

presumably because they could not afford sufficient dialysis.

Most Filipinos pay for their treatments without any subsidy from insurance.

Philhealth covers about 51% of the annual cost of treatment, if the maximum

benefit is claimed. The patient therefore has to pay for half of the treatment or at

least P150,000 per year. According to NKTI, only 15% of the partially-subsidized

patients are Philhealth members. Thus they have to pay for most of the

treatment, and are reliant on government assistance to afford any treatment.

This results to patients who can afford only partial therapy, which may be

sufficient to exist, but not enough to live. Patients without sufficient dialysis are

weak and display many of the symptoms that led to their diagnosis. They are

malnourished and unable to work, existing only until the next dialysis treatment,

whenever that may be.

In a survey conducted by five kidney specialists on patients with chronic

kidney disease from Bacolod City, Negros Occidental, from May to July 2002,

only 46% of 182 patients prescribed dialysis were able to start treatment. Among

those who started dialysis, 96% had inadequate treatment because they could

not afford it.

A family’s burden

Unfortunately, treating kidney failure is a burden borne not only by the

patient, but by the entire family. A family member or caregiver is needed to care
for the patient, attend to medications and meals, and assist in providing

treatment, whether by performing dialysis itself with PD or accompanying the

patient to an HD facility. Commonly, a family member has to stop working to care

for the dialysis patient. The patient is too weak to provide self-care and loses

independence.

Patients who cannot afford treatment rely on other family members to look for the

needed funds. Children stop schooling, savings are used up, objects of value are

sold, and all the earnings of those who work are used to pay for dialysis. This

results to families that are impoverished because of a single patient with kidney

failure who needs treatment. The cost of treatment therefore is not limited to the

cost of dialysis. Rather, the cost is multiplied a hundredfold, and becomes the

burden of an entire family.

Transplantation as the best option

Foreign and local studies have shown that kidney transplantation offers

the best option for patients with kidney failure. The quality of life of a transplant

patient is superior to one on dialysis (Lagula et al Philippine Journal of Internal

Medicine Jan-Feb 2002). A few months after the kidney graft is transplanted, the

patient becomes strong enough to return to work, and soon becomes self-reliant.

The family is able to rise from poverty and family members return to the labor

force or continue with their education.

The cost of transplantation for a government-subsidized patient and his

donor is about P200,000. It is a large amount to be paid at a single confinement

and equals eight months of dialysis. However the patient recovers sufficiently
and becomes healthy enough to go back to work, earning to pay for maintenance

medications, which now costs about P12,000 per month, or 48% of the monthly

cost of dialysis. It therefore becomes more cost-efficient to have a kidney

transplant, than to be maintained on dialysis which is life-long.

The quest for transplantation

Patients who develop kidney failure see transplantation as the only

solution to regain their lost lives. Funds are sourced to pay for the medical

evaluation required for this major operation. For those who are found medically

suitable to undergo transplantation, a willing kidney donor is needed.

Deceased donor kidneys have been sources of kidneys for decades.

Patients who lose brain function are sources of organs for the living.

In the Philippines though, despite years of advocacy promoting deceased

organ donation, only about 20 transplants from these donors are performed each

year. Barriers to this program include the difficulty of families of the deceased to

give their consent while the heart is still beating, or guilt when the potential

donor’s wishes were not known, and the fear of organs being removed from a

loved one.

Majority of transplants from deceased donors function immediately, due to

improvements in supportive care for the potential donor. An increase in the

number of transplants from deceased donors relies on referrals from all hospitals

admitting patients with massive brain injury from vehicular accidents, trauma, or

brain catastrophes like a stroke. Likewise, a massive educational campaign is

needed to inform Filipinos about the concept of brain death, and to make

deceased organ donation culturally acceptable.

Donors from relatives are the usual first source of organs. Parents,

siblings, uncles or aunts, nephews or nieces and first cousins are immediately

informed of the need for an organ. Many relatives assist patients with kidney

failure and volunteer as donors.

Unfortunately, diabetes and hypertension, which are the leading causes of

kidney failure today usually, run in families. Thus many times immediate relatives

become unsuitable donors. Likewise, even when a relative is willing, a blood test

that determines whether certain individual can be a donor or not, is positive,

meaning the donor is unsuitable.

The shortage of organs has led to spousal donation. And with the huge

success of transplantation from these unrelated donors due to improvements in

medicines given to prevent a transplant patient from rejecting an organ,

transplantation from non-related donors has become an acceptable and viable

option. Donor sources have expanded to friends, in-laws, church-mates or co-

employees. The sources of organs have multiplied.

Many studies have been done on kidney donors too. Taking away one

kidney from someone with normal kidney function allows the donor a normal life.

In studies on donors, there is a slight risk for developing high blood pressure and

finding small amounts of protein in the urine—after 20 to 30 years from donation.

But this has not been found to be progressive. Kidney donation thus remains a
safe procedure with minimal long-term effects and donors should have their

health status regularly monitored.

Kidney disease burden may be alleviated by transplantation

Transplantation has become the answer to many patients with kidney

failure. At the NKTI, 277 Filipinos received a kidney transplant in 2007. From this

number, 106 (38%) patients were partially subsidized by the Institute for the

transplant. The transplanted kidneys came from 130 related donors (47%), 120

non-related donors (43%), and 27 deceased donors (10%).

In the country, 510 Filipinos received a kidney transplant last year,

according to data from the Philippine Renal Disease Registry Annual Report in

2008. Among these, 170 (33%) transplants came from related donors, 313 (61%)

from non-related donors, and 27 (5%) from deceased donors. The number of

transplants last year, compared to the number who developed kidney failure, was

only 14%. Even if we assume that only half of those patients were found to be

medically suitable for transplantation, only 14% of the patients would have been

provided the option of kidney transplantation.

Kidney transplantation affords patients with kidney failure good health sufficient

to resume their normal lives. With this second chance at life, a better lifestyle

commonly emerges. Dialysis remains an excellent option, but for those who have

been transplanted, life just got better