PATIENTS’ AND RELATIVES’ EXPERIENCES OF PERITONITIS WHEN USING PERITONEAL DIALYSIS

Perceptions of peritonitis risk, prevention, diagnosis and stigma: Findings from a mixed methods study with patients and relatives using peritoneal dialysis

BACKGROUND

Peritonitis is the main treatment-related complication of peritoneal dialysis and a primary concern for patients and their relatives. Therefore, understanding their perceptions of peritonitis is important.

OBJECTIVES

To explore patients' and relatives' perceptions of peritoneal dialysis-associated peritonitis risk, prevention measures and experiences of diagnosis, and experience of perceived stigma.

DESIGN

A sequential mixed methods study design was used, including a questionnaire and semi-structured interviews.

PARTICIPANTS

Patients using peritoneal dialysis and relatives (n = 75) from six National Health Service organisations from the United Kingdom.

MEASUREMENTS

A structured questionnaire was administered with patients and relatives (n = 75) using peritoneal dialysis; data were analysed using descriptive statistics. Thirty questionnaire respondents were then purposively sampled and interviewed in-depth; data were analysed thematically. Data were collected 2017-2018. Ethical and governance approvals were gained.

RESULTS

Qualitative and quantitative analyses were integrated and three themes presented: • Perceptions of risk: participants assessed their risk of developing peritonitis and possible implications on their health and relatives. Participants felt greatly responsible for preventing infection. • Preventing peritonitis: participants reported similar and some differing measures to minimise their risk of developing peritonitis. Participants wanted to be seen as "clean". • Diagnosis of peritonitis: peritonitis diagnosis was embarrassing and stigmatising for many individuals. This was influenced by the response of healthcare professionals and the cause of peritonitis.

CONCLUSIONS

It is important that healthcare professionals are aware of how responsible patients and relatives feel about preventing peritonitis, the emotional effect of this responsibility and crucially the impact this may have on seeking help.

Hemodialysis and Peritoneal Dialysis Patients’ Problems: Patients’ Perspective

Background: End-stage renal disease (ESRD) can be fatal without hemodialysis, peritoneal dialysis, or kidney transplantation. Hemodialysis and peritoneal dialysis participants confront many adverse effects due to both the disease course and the treatment program. Objectives: This study was done to analyze hemodialysis and peritoneal dialysis patients’ problems. Methods: A qualitative exploratory study was used, and a purposeful sample of 55 hemodialysis and 47 peritoneal dialysis patients were interviewed. The data were collected through interviews. Initially, 12 open-ended questions were developed and used to stimulate discussions in interview sessions. Directed content analysis was used for the analysis of the transcribed data. After giving a code to each line or incidence, codes were then compared for similarity and differences, merged, and categorized. Results: Themes of fatigue, diminished ability, sleeplessness, wasting time, body impairments, travel, and free-time activities limitations, low blood pressure, displeasure and gratification with hemodialysis if peritoneal dialysis patients compliant of peritoneal catheter problems, peritoneal dialysis difficulties and limitations, and gratification with peritoneal dialysis emerged. Conclusions: Hemodialysis problems and patients' dependency on the hemodialysis machine and ward are at a high level, and patients’ gratification is at a low level. Peritoneal dialysis patients, who do not get the infection, are satisfied with the dialysis method, and the patients' limitations and problems are fewer, and they are relaxed and have more freedom.

Understanding the low take-up of home-based dialysis through a shared decision-making lens: a qualitative study

OBJECTIVES

To explore how people with chronic kidney disease who are pre-dialysis, family members and healthcare professionals together navigate common shared decision-making processes and to assess how this impacts future treatment choice.

DESIGN

Coproductive qualitative study, underpinned by the Making Good Decisions in Collaboration shared decision-model. Semistructured interviews with a purposive sample from February 2019 - January 2020. Interview data were analysed using framework analysis. Coproduction of logic models/roadmaps and recommendations.

SETTING

Five Welsh kidney services.

PARTICIPANTS

95 participants (37 patients, 19 family members and 39 professionals); 44 people supported coproduction (18 patients, 8 family members and 18 professionals).

FINDINGS

Shared decision-making was too generic and clinically focused and had little impact on people getting onto home dialysis. Preferences of where, when and how to implement shared decision-making varied widely. Apathy experienced by patients, caused by lack of symptoms, denial, social circumstances and health systems issues made future treatment discussions difficult. Families had unmet and unrecognised needs, which significantly influenced patient decisions. Protocols containing treatment hierarchies and standards were understood by professionals but not translated for patients and families. Variation in dialysis treatment was discussed to match individual lifestyles. Patients and professionals were, however, defaulting to the perceived simplest option. It was easy for patients to opt for hospital-based treatments by listing important but easily modifiable factors.

CONCLUSIONS

Shared decision-making processes need to be individually tailored with more attention on patients who could choose a home therapy but select a different option. There are critical points in the decision-making process where changes could benefit patients. Patients need to be better educated and their preconceived ideas and misconceptions gently challenged. Healthcare professionals need to update their knowledge in order to provide the best advice and guidance. There needs to be more awareness of the costs and benefits of the various treatment options when making decisions.

Seeking help for peritoneal dialysis-associated peritonitis: Patients' and families' intentions and actions. A mixed methods study

AIMS

To examine patients' and families' help-seeking intentions and actions when suspecting peritoneal dialysis-associated peritonitis.

DESIGN

A sequential explanatory mixed methods design was used, comprising a questionnaire and semi-structured interviews.

METHODS

A questionnaire was designed, piloted and used with patients and family members (n=75) using peritoneal dialysis from six hospital sites in Wales and England. Questionnaire data were analysed using descriptive statistics. A purposive sample of questionnaire participants (n=30) then took part in telephone or face-to-face semi-structured interviews. Interview data were analysed thematically. Data were collected between September 2017 and August 2018. Ethical and governance approvals were obtained; the study was reported on national research portfolios.

RESULTS

The quantitative data highlighted differences between participants' knowledge of when they should seek help for suspected peritonitis and their actions when they subsequently experienced peritonitis. The interview data revealed the complexities involved with recognizing peritonitis, making the decision to seek help and accessing healthcare. Some participants struggled to recognize peritonitis when signs/symptoms started, leading to delays in deciding to seek help. Furthermore, some participants reported that they accessed help from renal or generic out-of-hours and were misadvised or misdiagnosed, delaying diagnosis and treatment. The data were integrated using conceptual analyses of help-seeking behaviour and access to healthcare, which informs understanding of the complexity of seeking help in this context.

CONCLUSIONS

This study revealed differences between participants' help-seeking intentions and actions. Using the conceptual analyses of help-seeking behaviour and access to healthcare informs understanding of the complexity of the help-seeking process in this context. To safely use a home therapy, it is imperative that individuals recognize signs/symptoms of peritonitis, seek help promptly and are appropriately supported when they access healthcare. Further work is needed to examine how these individual and system changes can be enacted.

Scope and heterogeneity of outcomes reported in randomized trials in patients receiving peritoneal dialysis

BACKGROUND

Randomized trials can provide evidence to inform decision-making but this may be limited if the outcomes of importance to patients and clinicians are omitted or reported inconsistently. We aimed to assess the scope and heterogeneity of outcomes reported in trials in peritoneal dialysis (PD).

METHODS

We searched the Cochrane Kidney and Transplant Specialized Register for randomized trials in PD. We extracted all reported outcome domains and measurements and analyzed their frequency and characteristics.

RESULTS

From 128 reports of 120 included trials, 80 different outcome domains were reported. Overall, 39 (49%) domains were surrogate, 23 (29%) patient-reported and 18 (22%) clinical. The five most commonly reported domains were PD-related infection [59 (49%) trials], dialysis solute clearance [51 (42%)], kidney function [45 (38%)], protein metabolism [44 (37%)] and inflammatory markers/oxidative stress [42 (35%)]. Quality of life was reported infrequently (4% of trials). Only 14 (12%) trials included a patient-reported outcome as a primary outcome. The median number of outcome measures (defined as a different measurement, aggregation and metric) was 22 (interquartile range 13-37) per trial. PD-related infection was the most frequently reported clinical outcome as well as the most frequently stated primary outcome. A total of 383 different measures for infection were used, with 66 used more than once.

CONCLUSIONS

Trials in PD include important clinical outcomes such as infection, but these are measured and reported inconsistently. Patient-reported outcomes are infrequently reported and nearly half of the domains were surrogate. Standardized outcomes for PD trials are required to improve efficiency and relevance.

Developing a theory to help guide End-Stage Renal Disease Patients to adapt to Peritoneal Dialysis: A grounded theory study

AIM AND OBJECTIVES

The aim of this study was to develop a theory to help guide patients with end-stage renal disease to adapt to peritoneal dialysis.

BACKGROUND

Taiwan ranks first worldwide in end-stage renal disease incidence and dialysis prevalence. Many patients cannot accept long-term dialysis treatment and thus face several physical and psychological suffering. No theory has yet been developed to help guide patients with end-stage renal disease to adapt to peritoneal dialysis.

DESIGN

A grounded theory approach was used in this study.

METHODS

A theoretical sampling was performed after interviewing 25 patients who had adapted to peritoneal dialysis at a medical centre in Taiwan from January 2018 to September 2018; data saturation was achieved. Data were analysed using open, axial and selective coding and while using the constant comparison technique. COREQ reporting guidelines were utilised.

RESULTS

A substantive theory was developed to help guide patients with end-stage renal disease to adapt to peritoneal dialysis. The core category that emerged from the data collected was 'Confronting peritoneal dialysis to live and co-exist with peritoneal dialysis'. Other key categories linked to and embraced in this core category were as follows: positive self-regulation, regulation of daily life and the process of adaptation to dialysis method.

CONCLUSION

The results could help healthcare professionals to better understand the process of end-stage renal disease patients' adaptation to peritoneal dialysis, thereby facilitating patients' adaptation to dialysis in their daily life, enhancing their quality of life and improving the quality of medical care.

RELEVANCE TO CLINICAL PRACTICE

Healthcare professionals could use this theory as reference when providing care for peritoneal dialysis patients to assist them in adapting to life with peritoneal dialysis as soon as possible through positive self-regulation, daily life adjustments and the process of adapting to the dialysis method.

Methodological considerations when using ethnography to explore home care

BACKGROUND

Ethnography has been widely and successfully used in nursing and healthcare research, in particular to explore culture in clinical settings. Ethnographic studies are less often used to explore the effects of home medical technologies, despite the ongoing drive for patients to assume responsibility for their own care and to receive care at home.

AIM

To discuss methodological considerations when conducting ethnographic research in patients' homes, drawing on a study exploring the culture of patients and their families living with peritoneal dialysis in their homes.

DISCUSSION

In-depth insights obtained by observing participants in their homes, recording field notes through text and diagrams, minimising intrusion, and promoting participants' privacy with adapted periods of observation are examined. The author's role in caring for ill participants in the home is also covered.

CONCLUSION

Ethnography can generate holistic, rich data, but must be adapted when used in participants' homes.

IMPLICATIONS FOR PRACTICE

Ethnography can help healthcare professionals and policymakers to understand the effects on patients and their families of living with home medical technologies.

Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies

INTRODUCTION

Chronic kidney disease (CKD) requires patients and caregivers to invest in self-care and self-management of their disease. We aimed to describe the work for adult patients that follows from these investments and develop an understanding of burden of treatment (BoT).

METHODS

Systematic review of qualitative primary studies that builds on EXPERTS1 Protocol, PROSPERO registration number: CRD42014014547. We included research published in English, Spanish and Portuguese, from 2000 to present, describing experience of illness and healthcare of people with CKD and caregivers. Searches were conducted in MEDLINE, Embase, CINAHL Plus, PsycINFO, Scopus, Scientific Electronic Library Online and Red de Revistas Científicas de América Latina y el Caribe, España y Portugal. Content was analysed with theoretical framework using middle-range theories.

RESULTS

Searches resulted in 260 studies from 30 countries (5115 patients and 1071 carers). Socioeconomic status was central to the experience of CKD, especially in its advanced stages when renal replacement treatment is necessary. Unfunded healthcare was fragmented and of indeterminate duration, with patients often depending on emergency care. Treatment could lead to unemployment, and in turn, to uninsurance or underinsurance. Patients feared catastrophic events because of diminished financial capacity and made strenuous efforts to prevent them. Transportation to and from haemodialysis centre, with variable availability and cost, was a common problem, aggravated for patients in non-urban areas, or with young children, and low resources. Additional work for those uninsured or underinsured included fund-raising. Transplanted patients needed to manage finances and responsibilities in an uncertain context. Information on the disease, treatment options and immunosuppressants side effects was a widespread problem.

CONCLUSIONS

Being a person with end-stage kidney disease always implied high burden, time-consuming, invasive and exhausting tasks, impacting on all aspects of patients' and caregivers' lives. Further research on BoT could inform healthcare professionals and policy makers about factors that shape patients' trajectories and contribute towards a better illness experience for those living with CKD.

PROSPERO REGISTRATION NUMBER

CRD42014014547.

CUIDADO, DOENÇA E SAÚDE: REPRESENTAÇÕES SOCIAIS ENTRE PESSOAS EM TRATAMENTO DIALÍTICO

RESUMO Objetivo: analisar e comparar a estrutura representacional do cuidado com saúde e a doença entre pessoas em tratamento dialítico. Método: pesquisa qualitativa norteada na Teoria das Representações Sociais em sua abordagem estrutural, com 165 participantes, adultos, de ambos os sexos e tratamentos de hemodiálise e dialise peritoneal de quatro serviços de nefrologia em Curitiba e região. Os dados foram coletados entre junho de 2014 e maio de 2015, por meio das evocações livres aos termos indutores "cuidado com a doença" e "cuidado com a saúde" e tratados pelo software Ensemble de Programmes Pemettant L´Analyse des Evoctions e análise do quadro de quatro quadrantes. Resultados: os resultados revelam que as representações de cuidado com a saúde e a doença compartilham conteúdo da doença, mas possui organização distinta, a saúde com o enfoque dos hábitos de vida e dimensão biomédica e a doença ressalta o aspecto avaliativo. Conclusão: as representações de cuidado com a saúde e a doença interagem com comportamentos, atitudes e posicionamentos para o cuidado e fornece elementos para compreensão e apoio dos recursos individuais e ajustes da doença.

Patients' Perspectives on the Prevention and Treatment of Peritonitis in Peritoneal Dialysis: A Semi-Structured Interview Study

♦ BACKGROUND: Peritoneal dialysis (PD) is recommended for adults with residual kidney function and without significant comorbidities. However, peritonitis is a serious and common complication that is associated with hospitalization, pain, catheter loss, and death. This study aims to describe the beliefs, needs, and experiences of PD patients about peritonitis, to inform the training, support, and care of these patients. ♦ METHODS: Qualitative semi-structured interviews were conducted with 29 patients from 3 renal units in Australia who had previous or current experience of PD. The interviews were conducted between November 2014 and November 2015. Transcripts were analyzed thematically. ♦ RESULTS: We identified 4 themes: constant vigilance for prevention (conscious of vulnerability, sharing responsibility with family, demanding attention to detail, ambiguity of detecting infection, ineradicable inhabitation, jeopardizing PD success); invading harm (life-threatening, wreaking internal damage, debilitating pain, losing control and dignity); incapacitating lifestyle interference (financial strain, isolation and separation, exacerbating burden on family); and exasperation with hospitalization (dread of hospital admission, exposure to infection, gruelling follow-up schedule, exposure to harm). ♦ CONCLUSIONS: Patients perceived that peritonitis could threaten their health, treatment modality, and lifestyle, which motivated vigilance and attention to hygiene. They felt a loss of control due to debilitating symptoms including pain and having to be hospitalized, and they were uncertain about how to monitor for signs of peritonitis. Providing patients with education about the causes and signs of peritonitis and addressing their concerns about lifestyle impact, financial impact, hospitalization, and peritonitis-related anxieties may improve treatment satisfaction and outcomes for patients requiring PD.