TRENDANDI

SSUESI
NRENALNURSI
NG

Haksara,Ners.
,M.Kep.
Renal
Uni
tdr
.Soedj
onoArmyHospi tal
MagelangCent
erofJav
a
emai
l:ehaksara@gmail.
com

Abst
ract

Nephr
ologynur
sesf
acear
api
dlychangi
ngheal
thcar
elandscape,shi
ft
ingpat
ient
demogr
aphi
cs,anexpl
osi
onoft
echnol
ogy
,andamul
ti
tudeofev
ery
daychal
l
enges.
We need t
olear
nto use st
rat
egi
cthi
nki
ng t
oident
if
yissues,col
l
abor
ate wi
th
deci
si
on maker
s,and under
stand who hast
hepowert
o cont
roldeci
sionsand
r
esour
ces.Changest
aki
ngpl
acei
nthenur
singpr
ofessi
oni
ngener
alandnephr
ology
nur
sing speci
fi
cal
l
yhav
ebeen dr
iven bysoci
oeconomi
cfact
ors,aswel
lasby
dev
elopment
sinheal
thcar
edel
i
ver
yandpr
ofessi
onali
ssuesuni
quet
onur
sing.Thi
s
ar
ti
cler
evi
ewsf
iveoft
hesei
ssuesandt
hei
rimpactonnephr
ologynur
sing.

Thef
iel
dofmedi
cinei
srecogni
zi
ngt
hei
mpor
tanceofpat
ient
-cent
eredcar
eand
qual
i
tyofl
i
fe,
thought
ful
l
yconsi
der
ingpat
ient
s’v
aluesandgoal
ssot
hatcar
ecanbe
ef
fect
ivel
ytai
l
ored t
o suppor
tthose goal
s,whi
ch mayi
ncl
ude t
he del
i
ver
yof
suppor
ti
veorpal
l
iat
ivecar
e,whennecessar
y.Tot
hisend,t
hree“
bestpr
act
ices”ar
e
pr
ovi
ded:1)nur
tur
eashar
eddeci
sion-
maki
ngr
elat
ionshi
p,2)pr
ovi
demet
icul
ous
pai
nandsy
mpt
om management
,and3)pr
ovi
deorcol
l
abor
atewi
thsuppor
ti
vecar
e
orhospi
ce i
nthe t
reat
mentofser
iousl
yil
lki
dneydi
sease pat
ient
s.As r
enal
pr
ofessi
onal
s,i
tmaynev
erbe“
easy
”tof
acet
hesei
ssueswi
thpat
ient
s,f
ami
l
ies,
and
car
egi
ver
s;howev
er,appl
yi
ng t
hesebestpr
act
iceswi
l
lhel
pinpr
ovi
ding qual
i
ty
suppor
ti
ve,
end-
of-
li
fecar
etopat
ient
s.

Keywor
ds:
Nephr
ologynur
ses,
ski
l
lsandcompet
ence

stagesandhasbeenani ntegralpar
tof
I
ntr
oduci
ng socialmov ements.Nursinghasbeen
i
nv ol
ved i
nt hecul t
ure,shaped byi t
Nursi
nghasbeencall
edtheoldsoft
he andy etbeingtodev el
opei t.Thetren
ar
t,andt
heyoungestoft
hepr of
essi
on. analysi
sandf uturescenar i
ospr ovi
de
Assuch,ithasgonet hroughtmany a basisf orsound deci sion making
thr
ough mappi
ng ofposi
blefutures wor
ldwi
de.
andaimi
ngtocreat
epr
efer
redf
utures.
The l i
st we’ ve compi l
ed bel ow
Thef uturewillseegr eatadv antagesi n hi
ghli
ghtsalloft
hesetrendsandmany
prev ention,dagnosi sandt r
eat mentof moret hatare changi
ng the fi
eld of
i
llnes and di seases wi thi ncreasing nur
sing todayfort he bet
ter
mentof
demand f orheal th car e and heal th
medici
net omorr
ow.
i
nf ormat ion. As l arge hospi tal are
repal ced by hi gh t ech and smal l
hospi tal,heal
thcar ewi llbepr ovidedin A. Fi
ve chal
lenges i
mpact
ing
homesandoutr eachf acil
it
iesandt he
nephr
ologynursi
ng
focuswi l
lbepr oviderski l
l
,outcomes
anduserpr eferenceandsat isfacti
on. Nephr ol ogy nur ses f ace a r api
dly
Nur sewi l
lbepr eferredcar epr ov i
ders
changi ng heal t
h car e l andscape,
andent rypointfordiv ersservices.
shif
ting pat ient demogr aphics, an
Since2010,t heAf for dabl eCar eAct explosi on of t echnology , and a
and f i
nanci alcr isis hav ei nf ormat ive multitudeofev erydaychal lenges.We
i
mpact ed t he heal thcar ei ndust ry at needt ol ear
nt ousest rategict hi
nki
ng
everyl ev el.Cal l
sf ort ranspar encyi n toi dent i
fyissues,col l
abor ate wit
h
healthcar e bi ll
ing as wel las i nter- decisionmaker s,andunder standwho
professi onal col labor ation among hast hepowert ocontroldeci sionsand
doct or s,nur ses,hospi talst aff and resour ces.
i
nsur ancepr ov idersf ort hepur poseof
1.Legi
slat
ionandr
egul
ati
on
higher qual ity car e hav e made
healthcar e organi zat ions mor e "Nephr
ologynur sescanno l onger
account ablef ort hei rcost s.Nur ses aff
ordtor emaininthebackgr ound
especi allyhav ef el tt heendur i
ngst ing ortobeaddedasanaf ter
thoughtto
of t he f i
nanci al cr isis, and t hey thepol
icyandlegisl
ati
vearenas."
cont i
nuet ost ruggl ewi thhi ghpat i
ent-
to-nur ser atios,adecl i
ningpopul ation Nephr ologynursesf acechal lenges
of nur se educat ors,and an agi ng associatedwi thpat i
entsaf etyand
wor kfor ce t hati sl ikelyt or etire en sati
sfact i
on, access t o ser vices,
masse v ery soon. Howev er , such cli
nicaloutcomes, healt
hdi spariti
es,
setbacks and li
abi li
ties are and r egulator
y changes. Deal ing
count er bal anced by t he hope of a with t hese concer ns and ot her
growi ng cohor t of wel l
-educat ed, workplacei ssues,nurseshav et he
young nur seswho ar emeet ing hi gh choicet ocont i
nuet r
yingt omake
demandst o car ef ort he el der l
y ;an do whi le feeli
ng v ictimized by
i
ncr easi ng emphasi s on hol istic and current changes or t o mot ivate
prevent ive medi cine that i s themsel vestot akeact i
onandf ind
empower ing nur ses i nt he r ealm of oppor t
uniti
estobr ingaboutchange
primar ycar e;aswel lasar i
si ngt i
deof i
nt he heal t
h car e sy st
em i tself
technol ogical i nnov ation t hat i s (Mick,2004).
produci ng new car eersf or nur ses
I
nasur veyr el
easedbyt heRober t become a strong voi
ce acti
vel
y
WoodFoundat ioni n2010,75% of advocat
ingf
orposi
ti
vechange.
opinionl eadersr ankedgov ernment
offi
cialsashav ingagr eatdealof
2.Adv
ancesi
ntechnol
ogy
i
nfluence i n heal t
hr eform int he
nextf i
vet o10y ears,compar edto The r apid growthi ni nformation
theirranki ngs oft he infl
uence of technol ogyhasal readyhad af ar-
i
nsur ance execut i
ves (56%)
, reachi ng impact on heal t
h car e
pharmaceut i
cal execut i
ves ( 46%)
, delivery. Adv ances i n di gital
health car e execut i
ves, ( 46%)
, technol ogy hav e i ncreased t he
doctors( 37%),pat i
ents( 20%)and appl i
cations of t eleheal t
h and
nurses( 14%) . telemedi ci
ne, br i
ngi ng t ogether
pat i
ent and pr ovider wi thout
Opinion l
eadersi dentif
ied the top
phy sicalproxi
mi ty.Nanot echnology
barri
erst o nurses’hav ing gr
eater
willintroducenew f ormsofcl inical
i
nfluenceonheal threfor m asnot
diagnosi sandt r
eat mentbymeans
bei
ng per ceived as i mportant
ofi nexpensivehandhel dbi osensors
decisionmaker s( 69%)orr ev
enue
capabl eofdetect i
ngawi der angeof
generator
s( 68%) compar ed with
diseases.
doctors,and nur ses nothav i
ng a
si
ngl evoi
cei nspeakingonnat i
onal Accessi bil
ityofcl i
nicaldat aacr oss
i
ssues( 56%). settings and t i
me has i mpr oved
both outcomes and care
I
ti sgener al
l
yassumedt hatnur ses
management .Thr ought heI nt ernet
,
l
ackt hepowert obeef f ectiveinthe
patientswi l
lbei ncreasinglyar med
l
egislati
vear ena.Nursescont ri
bute
with informat i
on pr
ev iously
tot his assumpt ion by descr i
bing
availableonl ytocl i
nici
ans.Theuse
themselvesaspower less.Whet her
of el ectronic medi cal r ecor ds
nephrologynur ses recogni ze itor
i
mposes si gnif
icantchal l
enges t o
not,t hey arei mpact ed dai ly by
thenur se.I nsomei nstancest asks
poli
cies,legi
slati
on,andr egulat
ions
previously t aking seconds t o
developed by non- nur
sing
compl ete on paper now r equire
i
ndividuals.
mor e t ime wi th mul tiple cl i
cks
Nephrologynur ses can no l onger throughamazeofmenus.
aff
ordt oremaini nthebackgr ound
Innephr ologyt hereist headdi ti
onal
ortobeaddedasanaf t
erthoughtt o
burden t o use mul ti
ple sy stems,
the poli
cy and l egi
slative arenas.
eachwi thitsownsecur it
ysy stem
Nephrology nur ses hav e t he
and r egistr
ation r equirement s,t o
potenti
alto successfullyadv ocate
meet t he r equirement s of t he
forthei
rpatient
sandt hei rpractice.
Qualit
yI ncent i
ve Pr ogr am ( QIP).
Theyhav eauni queper spectiveon
Currentl
y ,dat a ent ryi sr equired
healt
hcar epoli
ciesandexper tiseto
thr
oughcl ai
msr eports,CROWNWeb,
share. Nephrology nur ses must
 and t he National Health Safety evidence-based car e. Ar t
icl
es,
Networ k (NSHN) . The Amer i
can webi nars, and presentati
ons are
Nephr ol
ogyNur sesAssociat
ionhas schedul ed thr
oughoutt he yearto
recentlymetwi ththe Cent
ersf or focusont hisimportantt opi
c.But
Medi care&Medi cai
dServi
ces(CMS) thatef f
ortisnotenough.Thebest
tor einfor
ce the crit
icalneed t o wayt omakeev i
denced-basedcare
i
nclude nephrology nurses inthe ar eali
tyistohavenephr ol
ogynurse
developmentandi mplementati
onof l
eader s encourage evidence-
based
thesesy st
ems. practiceatthechair
side.

4.Cr
ossi
ngbor
der
s
3.Ev
idence-
basedpr
act
ice
Licensur er equi rement sf ornur ses
Thei mpor tanceofev idence- based aredi fferenti neachst at e.Fr om a
pract i
cei snotnew.Nur ses( aswel l l
egal st andpoi nt, a pr of essi onal
as phy sicians) cont inue t o f ace nur sel icensei sanaf firmat ionbya
bar r
ierst oi mpl ement ation.These duly const ituted body ,usual lya
bar r
iersi ncl ude t ime const raints, stat e,thatanur sehasmetcer tai n
l
imi tedaccesst ot hel iterature,l ack prescr i
bed qual i
ficat i
ons and i s
of t r
ai ning i n i nterpr etation of ther eforer ecogni zedundert hel aws
resear ch,andawor kenv i
ronment of t he st ate as a nur sing
that does not encour age prof essi onal.TheNur seLi censur e
i
nf ormat i
on seeki ng.Get ti
ng past Compactal lowsanur set opr act i
ce
the wor kpl ace r estraint and t he i
nanyCompact -par ti
ci pat i
ng st at e
comment sl ike,“That ’
st hewaywe ont hehome- stat elicense.Thus, the
hav e al way s done i t
”r emai nt he Compact i s of ten ci ted as t he
biggestbar r i
ertonur sesr eadi ness answert oquest ionsaboutl icensur e
and wi l
lingness t o embr ace j
ur i
sdi ction for cr oss- bor der
ev i
dence- based pr act ice. For pract ice.Todat e,howev er,onl y24
exampl e, t he t reat ment f or stat eshav echosent obel ongt ot he
hy potensi ondur ingahemodi alysis Compactandconcer nsexi stabout
treatment f or decades was a i
tsconsequences.( ANA,2012) .A
trendel enbur g posi tion. Ev idence signi fi
cantconsequencecr eat edby
hasshownust hisisnol ongert he compactl i
censur ei st he i nabi l
ity
besti nt ervent ionfort hepat i
ent ,y et nat i
onwi de t o keep nur ses f rom
pract i
ce ( and pol ici
es)i s sl ow t o avoi ding the penal ti
es of
change. mi sconductbyhoppi ngacr ossst at e
l
ines.Cr iti
cssayt hecompactmay
Educat
ion is another bigf actor.
act uallymul ti
plyt her i
skt opat ient s.
Nursi
ng educationalprograms 20
Ther eisnocent rall i
censi ngf ort he
years ago did not addr ess an
compact ,sopol icingnur sesi sl eft
evi
dence-based approach to care.
tot hev i
gi l
anceofcompactmember
ANNAhasmadeacommi tmentt o
stat es.Butmai nt ainingt hecur rent
educat
et he nephrol
ogy nurse in
 l
icensur epr ocess,wher eeachst ate ofnur si
ng care( e.
g.,f
ewerf al
ls,
l
icenses and di sci
pli
nes i ts own fewer inf
il
trat
ions)
.Much of t he
nur ses, cr eat es chal lenges. For burden ofmeasur ementand dat a
exampl e,t hismeanst hati fanur se coll
ecti
on fall
s on nurses.Ther e
pract i
cing as a CKD Educat oror needst obeaf ocustoensur ewe
homet rainingnur sepr ovidescar e aremeasur i
ngt heri
ghtthingswith
toapat i
entnoti nhis/ herlicensed aslit
tleburdenofmeasur ementas
stat e( and t he st ate wher et he possibl
e.
pat i
enti sl ocat edi snotamember
oft heCompact )t henur semustbe ANNAi sinthepr ocessofdef ining
l
icensed i n bot h st ates: wher e nephrologynur se sensit
ive quality
she/ he r esides and wher e the i
ndicators uti
li
zing a broad-based
pat i
ent i s dur ing the t elephonic approach t o i ncl
ude st ructur al
,
i
nt ervention. process,and out come measur es.
These i ndi
cators wi ll addr ess
Thisi ssuei smostev i
dentdur ing i
mpl i
cations for cli
nicalpr actice,
weat her-
related di sasters when research, educati
on, and publ ic
speciall
yt rainednephr ologynur ses poli
cy.
are unabl et o deploy to af f
ected
states due t o licensure issues.
B. Provi
ding suppor
ti
ve car e t
o
ANNA i swor king witht he Kidney
pati
entswi
thki
dneydisease
Communi ty Emer gency Response
Coal i
ti
on ( KCER) t o dev elop a Inst
ead of assumi ng t hat li
fe
processt hatal lowsnur sestomor e prol
ongat i
on ist he singl
e most
smoot hly obt ain per mission t o i
mpor tant goal, patient-
cent
ered
crossst atelinest owor kinaf f
ected care helps pati
ents and famili
es
states. real
isti
call
ybalancequal i
tyoflife,
comf ort
, and t he burdens and
5.Nur
sesensi
ti
veout
comes
benefit
soft r
eat
ments.
Nursing-sensitiveout comesr eflect
1. Changesi
ndef
ini
ngt
hev
alueof
the st r
ucture, pr ocess, and
heal
thcare
outcomes of nur sing car e. The
numberofnur si
ngst affondut y,t he Health car ei si nt he mi dstofa
skil
lleveloft hosenur singst aff,and paradigm shi ft
.Formanyy ears,the
thei
reducat ion/cer t
ifi
cat i
oni ndicat e primary goalwas t o extend l i
fe,
the st ructure of nur sing car e. somet imes at any cost ,without
Process i
ndicators measur e consider at
ionofi t
squal ity.Today ,
aspects ofnur sing car e such as the field of medi cine is mov ing
assessment ,int erv
ent i
on,and RN towardanal i
gnmentwi t
hpat ients’
j
ob sat i
sfact i
on.Pat ientout comes and f ami li
es’v al
ues and goal s.
thataredet ermi nedt obenur si ng Consist entwithpr i
nciplesofpat i
ent
sensiti
vear et hoset hati mpr ovesi f -cent
er edcar e,therei saconcer ted
thereisagr eaterquant it
yorqual ity effor
tt oconsi derwhatt hepat i
ent
want sandef fecti
velyt ail
orcar et o receivedhospi cecar eatt het imeof
suppor tt heir wi shes.I nstead of death.Thi si sani mpr ov ementov er
assumi ng t hatl if
epr olongat i
on i s the11%whousedi tin2000,buti s
the si ngl e most i mpor tant goal , stil
lmuchl owert hanf ormanyot her
patient-cent eredcar ehel pspat i
ent s diseases. Thi s i s par t
icularl
y
and f ami lies r ealisti
cally bal ance troubli
ngwhenoneconsi derst hat
qualit
y of l if
e,comf ort,and t he dialy
sispat i
ent shav esomeoft he
burdensandbenef i
tsoft r
eatment s. highestsy mpt om bur dens ofany
Thegoal sofsuppor t
ivecar e,al so chronic disease popul ati
on.Many
referr
edt oaspal l
iativecar e,ar et o dialy
sis pr ofessional s find
rel
ieve, r educe, or pr event themsel vesi nt he pr edicamentof
sympt oms and suppor tt he best want i
ngt opr ov i
desuppor ti
vecar e,
possibl equal i
tyofl if
ef orpat i
ent s especiall
y sy mpt om management
andt hei rf ami li
es,whi l
eel ici
tingand and r eferral t o hospi ce when
respect ingpat i
entandf ami l
yv alues appropr i
ate,butf eelill
-equippedt o
andpr ef er ences.Pr olongingl ifei s do so.Recentr esear ch i ndicates
not appr opr i
ate i f i t ov erri
des that suppor ti
v e car e needs ar e
patients’v aluesand i sassoci at ed going unmeti n di aly
si s and t hat
withi ntract ablepai nandsuf fering. manypr ofessi onal sareunawar eof
Mor eov er ,r esearchhasshownt hat , the tools and r esour ces av ail
able
i
n some chr onic di sease st ates, thatmayenabl et hem t o pr ovide
palli
ative car e or hospi ce can suchcar e.
actuallyext endl i
fewhi l
ei ncreasing
patients’ heal t
h-rel
at edqual i
tyofl ife. Establ i
shed in 2005 by t he Mi d-
At l
antic Renal Coal i
ti
on ( ESRD
Thenumberofpat ientsbenefi
ting Net wor k 5) ,t he Coal i
ti
on f or
fr
om t hecompr ehensivesy mptom Suppor t
iveCar eofKi dneyPat ient s
management and comf ort care (CSCKP)i sanat ionalor ganizat i
on
provi
dedbyhospi cepr ogr
amshas ofr enaland pal l
iat i
vecar eheal t h
grownr apidl
yoverthepastdecades. care pr of
essional s,pat i
ents,and
I
n 2013, 47% of al l Medicare fami l
iesseeki ngt ot r
ansform car e
benefi
ciarieswhodiedusedhospi ce delivery so t hat al l pat ient s
– mor et handoublet he23% who diagnosed wi t
h adv anced CKD or
useditin2000. ESRD ar e offered suppor ti
ve car e
from t hetimeofdi agnosisandar e
Howev er,this t rend has been prov i
dedwi thal lt reatmentopt i
ons,
significantl
y sl ower f or ESRD i
ncl uding end- of-l
i
fe and
pat i
ent s t r
eated wi th di alysi
s. bereav ementcar e.TheCSCKPai ms
Accor di ng to t he most r ecent to cr eate cul ture change t hat
hospi cedat a(2012)av ai
labl
ef rom transforms t he t r
eatment of
the Uni t
ed St ates Renal Dat a persons wi th ki dney di sease by
Sy st
em ( USRDS) , only 25% of puttingev erypatientatt hecent erof
Medi car e benefi
ciaries wit
h ESRD his or her car e and i ntegrat i
ng
pall
iat
ive pr
acti
ces t
hroughoutt he speci f
ic pat ient r at her t han
careconti
nuum.Aspar tofthi
sgoal, ov erwhel mi ngapat ientwi tha
the CSCKP suggestst hree “best broad ar ray ofopt ions whi ch
practi
ces” f or managi ng t he may be uni mpor t
ant or
symptomsofESRD. unaccept abl e. Shar ed- decision
maki ngi sal sonotaone- ti
me
ev ent ,butr atheran ongoi ng
a. Nur
tur
e a shared deci
sion-
process,aspat ientpr eferences,
maki
ngrel
ati
onshi
p
treat ment r
egi men, and
Shar ed deci sion maki ng has prognosi s change.
been def ined as a pr ocess Document ati
on of pat i
ent
i
nv olv ing atl eastt wo par t
ies, pref erences and v alues i s an
the pat i
ent and phy sician, i
mpor tant par t of shar ed
shar ing i nfor mat ion t o bui l
d deci sionmaki ng,sot hatot her
consensus and r each an heal thcar epr oviderscanhonor
agreement about t r
eat ment . these pr eferences i
n
Aski ng pat i
ent s and t heir subsequentepi sodes ofcar e.
fami liesorcar egi verswhatt hey Est ablishingar elationshi pwi th
wantand el iciti
ng t heirv alues pat ientsf rom t hebegi nningi s
andpr eferencesi satt hehear t fundament al t o successf ul
of shar ed deci sion maki ng. pat ientcar eand wi llser v eal l
Such communi cat i
on may be par ties ( e.g., pat i
ent ,f amily,
chal lengi ngatt i
mes,especi ally car egiv er
s,phy sician,andot her
i
n a noi sy di al
y sisf acil
ity or heal thcar epr ofessi onal s)wel l.
hect ic nephr ology pr actice;
b. Pr
ovide met
icul
ous sy
mpt
om
howev er , l
ear ning and
management
under st anding patients’
prefer ences and v alues i s Pai n i s a common and
crit
ical l
y necessar y so t hat frequent ly bur
densome
cli
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ent swi th
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options and make est i
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recommendat i
ons t o t hem 50% of ESRD pati
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h t heir exper i
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,
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reatedi n75%
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i
s t rul y i mpor tant t o t hat
be assessed i n pat ients wi t
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s
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cause f urtherki dney damage. uses r epor ti
ng measur es t o
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s l
ead t o cl inicalmeasur es i n
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ver epor t
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and, speci f
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ogistwi thpal liativecare
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treati
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al CSCKP r ecommends ear ly
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om
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patient t wice dur i
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ecan be
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l
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simul taneousl yaccesspay ment hospi cewoul dnotber ei mbur sedby
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pat i
entent eringhospi cecar ei s This i s because t he Medi car e
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and f orgo cur ative or l i
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phy sician.Pat i
ent smaychange make a consci ent ious ef fortt o
theirmi nds af terenr olling i n i
nclude compr ehensi ve ser vices
hospi ce, r ev oke t he hospi ce needed by pat ient s,t he f inanci al
benef i
t,and r eturnt or egul ar reali
ties ofr eimbur sementr equi re
Medi care benef i
ts, i ncludi ng many hospi ces t o l imi t v ery
dialysis cov erage.Addi t
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pat i
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i
fapat i
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hasat ermi naldi agnosisofl ung Nev ertheless, i t i s cr i
tically
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ny ourcommuni t
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t& some hospi ce or gani zat i
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when,apat i
entmayqual ifyf or dial
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hospi cebenef i
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2. Hospi
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s unr elated t o ki dney f ai
lure,
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Ifapat ient’
st er
mi naldiagnosisi s
hospi cecar eanddi alysistr eatment .
kidney fail
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Medi car e per mit
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i
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iat
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payment s t
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enrollinhospice,thepat ientisnot
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thedi alysisprov i
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rel
at edESRDcar e,agai n,onl yifthe
benefit
s.Thehospi ceor ganization
termi naldi agnosisis unr elated to
woul dber esponsibleforpay i
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 kidneyf ail
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of CSCKP and ot her nephrology pract ices and t ools out li
ned i nt his
organizat i
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ir
medt hat article, also av ail
abl e at
patientswhohav easepar at
e( non- www. kidney suppor tivecar e.org,wi llbe
ESRD) t ermi nal diagnosis may helpf ul t o r enal pr ofessi onals i n
cont i
nue t o dr aw f r
om bot h prov idingqual itysuppor tiveandend- of
pay mentst reams—“ Ifthepat ient’
s -l
ifecar et ot hei rpat ients.Encour aging
terminalcondi ti
oni snotr el
atedt o and par ti
cipat ing i n shar ed deci sion
ESRD, t he pat i
ent may r ecei v
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hpat ient sandt heirl oved
cov er
ed ser vices underbot ht he onescanhel pal li nvol vedcr eat ean
ESRD benef i
t and t he hospi ce appr oacht ocar ewi thwhi chev eryone
benef i
t. Hospi ce agencies can i
s comf or tabl e. The r elati
onshi ps
prov i
dehospi ceser vi
cestopat i
ents formed t hrough shar ed deci sion
who wi sh t o cont i
nue di alysi
s maki ng wi llhel p keep t he l i
nes of
treatment .” communi cat ion open, whi ch i s
essent ial as needs and pr ognosi s
Justas di alysis organi
zati
ons ar e change. Thi s t ype of heal th car e
addressing reducti
ons i
n prov ider /pat i
entr elationshi pmayal so
rei
mbur sement s,sot ooarehospi ce encour age pat ient st o shar e mor e
organizati
ons. For i
nstance, about t heir sy mpt oms,as not al l
hospices ar e under i ncreasing pat i
ent sar ef or thcomi ng aboutt heir
pressuref rom Medi car
et oj ustif
y sy mpt oms or pai n, and t hereby
any ex penses t hat are bil
led t o facilitate bet ter assessment and
Medicar e outside oft he hospi ce treatmentbycl i
ni ci
ans.Wor kingwi tha
benefit.Addi t
ionaldocument at
ion palliativ e car e speci alist may be
and rationale maybe r equired to necessar y when sy mpt oms become
adequat el
y det er
mi ne whether or mor e chal lengi ng t o manage and
notapat i
enti seligi
bleforhospi ce refer r
alt o hospi ce mayneed t o be
andwhi chr ei
mbur sementst reams consi der ed.Hel pingpat i
ents,f ami l
ies,
maybeused. and car egiv er s under stand t heir
opt i
ons,assi stingt hem i ncompl et i
ng
adv ance car e pl ans,and ul timat ely
Summar
y respect ing t hei r wi shes ar e al l
encompassed wi thint he del ivery of
Nephrology nur ses ar e continuall
y pat i
ent -cent er edcar e.
faci
nguni quechal l
engesint hei
rwor k
envir
onment s. The dev elopment of
skil
l
s t o hel p nav i
gate t hese
chall
engeswhi l
econt inui
ngt oprovide Ref
erences
quali
tycareiscri
t i
cal. Amer i
canNur sesAssoci
ati
on,Nursing
Whil
eitmaynev erbe“ easy”tof
ace World:I
nterstateNur
seLicensure
t
hese i
ssues wi
th pat
ients,fami
l
ies, Compact: States99Part
ici
pati
ngin
theNurseLicensureCompact ;
li
nking
totheNational CouncilofStateBoar
ds SchellJO,Ar nold RM.NephroTalk:
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