MENTAL HEALTH ISSUES IN DIALYSIS CARE

1. MENTAL HEALTH ISSUESIN DIALYSIS CARE

2. SEAN HARVEY, D.O. • CERTIFICATIONS: Nephrology, Internal Medicine, Psychiatry, Addiction Medicine, Pain Management, Electroconvulsive Therapy, Clinical Specialist in Hypertension, Holistic Medicine, Hospice and Palliative Care, Substance Abuse Professional and Medical Review Officer

3. Dialysis is hard! • Many types of patients will act out fears, frustrations, etc. • Stages of loss • Denial • Anger • Bargaining • Depression • Acceptance * Look at how much we may lose if we were on dialysis (true empathy) *

4. GENERAL RULES • Know general limits of behavior that a unit will tolerate • Safety first • Patients and staff need to feel “heard” with concerns • It is ok to discharge some patients from a unit, as long as significant efforts were made to resolve conflicts • We don’t have to like all of our patients, but that above is not grounds for discharge • Document!

5. GENERAL RULESContinued • Referral to Mental Health professionals • Have ready access, social worker, other certified counselors, psychologist, psychiatrists • Never punitive • First introduction of referral should be empathic

6. CASE STUDIES WITH DISCUSSION AND DIDACTICS

7. Facility staff called to discuss a patient who appeared to be delusional and whose behavior was making it extremely difficult to treat him/her. The patient’s behavior was sufficiently disruptive so that the facility chose to schedule the patient late in the day when there were fewer other patients. The patient called self, “The Prophet Isaiah.” The patient’s behaviors included belligerence, exorcising demons from patients and staff, calling the police saying there was Anthrax on the patient’s chair side table (police told him/her to stay on treatment and did no further investigation). The patient became angry and distrustful of all staff at various times and threatened, “I will shoot you with my .45”, on two occasions.

8. Other patients had spoken to the facility head nurse concerning this patient and one of them called the Network regarding this patient. Their concerns included being frightened by this patient’s behavior. The Network staff first suggested to the facility that it make a psychiatric referral and document all attempts to meet this patient’s needs. The patient refused psychiatric care and did not show up for a neuropsychiatric appointment that was made. At one point, the patient called the Network, saying that, “sure one of the technicians was using a screwdriver to mess around with the inside of the machine”. (Patient also called OSHA).

9. When Network staff talked with facility head nurse, it was discovered that nobody had made any adjustments to the dialysis machine on that day. The patient called the state agency with a complaint that a nurse was trying to poison the patient and subsequently, the state agency said the unit could discharge the patient because of the shooting threats. Three weeks after initial contact, the patient’s physician discharged this patient because of threats to the staff, disruptive behavior disturbing to the care of other patients (e.g., casting spells, exorcising demons), refusal to have routine dialysis blood tests performed and twice threatening to shoot staff with a specific weapon.

10. Paranoia Definitions • Pervasive distrust and suspiciousness of others that their motives are malevolent • Perfect awareness

11. “PARANOIA” Differential includes: • Realistic concerns • Control issues • Obsessiveness • True clinical paranoia • Schizophrenia • Paranoid delusional disorder • Paranoid personality disorder • Perhaps PTSD • Anxiety disorders

12. SCHIZOPHRENIA • 2 or more present • Delusions • Hallucinations • Disorganized speech • Disorganized or catatonic behavior • Negative symptoms, I.e., flat affect, social isolation, alogia, avolition (Only if delusions are bizarre or hallucinations consist of a voice with a running commentary)

13. Social / occupational dysfunction • Duration – 6 months with at least 1 month of continuous symptoms • Other ruled out Types of Schizophrenia: - paranoid - disorganized - catatonic - undifferentiated - residual

14. SCHIZOPHRENIA - GENERAL • 1% of all populations studied (just under) • Males peak incidence 17y/o-22y/o • Females peak incidence 17 y/o – 37 y/o • No clear etiology yet, but associated with chromosomes 6 (also 4, 8, 15 22) • Second trimester disorder • 50% concordance rate for monozygotic twins • Births – highest in March lowest September

15. Dopamine Theory Especially Dz receptor All current medications have Dz affinity Glutamate – NMDA receptors Comorbid Conditions Alcohol use disorder 33.7% Drug use disorder 27.5% Combined 47% “Dual-Diagnosis” or “MICA” Marijuana Nicotine

16. 3 KEYS TO APPROACH • Explain everything • Primary care givers should be someone the person trusts • Have a trusted person introduce new persons, procedures, changes, etc.

17. Facility staff called to discuss a patient’s recent behavior caused the staff to become interested in discharging this patient. The patient said to one staff member, “If I had two good legs, I’d get out of this chair and beat the s*** out of her.” This patient had a history of “hostile behavior”, broke a pervious treatment contract, was late to every treatment, expects to be put on right away, talks loudly and in a hostile manner to staff. Other patients have complained about this patient’s language and loudness. The patient did not make this comment about “beat….” directly to the staff member about whom it was said, it was said later to a different staff person.

18. Network staff asked for more details about the nature of the specific “threat”, more background information on general behavior, discussed Federal Regulations regarding patient discharge, examined facility records regarding behavioral contract, offered suggestions on dealing with disruptive behavior (screaming, swearing) such as an immediate termination of treatment but allowing the patient to return for next scheduled treatment. Network staff stressed how important it was for the staff to explain carefully what it expected regarding behavior and what the consequences will be if the unacceptable behavior recurs. In general, contracts with 30 day time periods are suggested for situations like this.

19. Result: The patient was NOT discharged. A few weeks later, while discussing an un-related issue, the staff member mentioned that the patient had apologized to the staff member for the pervious outburst.

20. ANTI-SOCIAL PERSONALITYDISORDER Formerly “psychopath or sociopath” - failure to conform to social norms - deceitful - impulsivity or failure to plan - irritability and aggressiveness (i.e., frequent fights) - consistent irresponsibility (work, finances, etc.) - lack of remorse

21. 3 KEYS TO APPROACH • Respect, not a parental attitude • How can it benefit THEM • Peer involvement Most importantly – PICK YOUR BATTLES!

22. Case 1 Description – Pt. called reporting she is a manic-depressive dialysis patient. It seemed apparent to the NW PSC that pt. was experiencing a manic episode. Spoke with caller for over 60 minutes. Pt. had complaints about the dialysis industry, staff, dialysis in general and the federal government. PSC focused on pt. to discover pt. had missed her ambulette rise this morning and it too tired to do anything about it. Pt. said the unit had called her several times and since they did not understand her concerns she hung up on them.

23. Resolution - MW staff spoke at length to pt. about her concerns. Suggested pt. request transfer through her Social Worker. Pt. stated she has internet access and can utilize the DFC website. Suggested to caller NW staff can contact facility and advocate on her behalf. Caller discontinued call to answer a call from the dialysis unit. Caller stated she would call again if necessary. Caller called back to report she spoke to the unit SW and requested a transfer and is going to get Tx tomorrow. NW staff asked if she was actually put on the schedule. Caller reported she hung up on the SW before she found out.

24. NW staff spoke to Unit SW who reported pt. is scheduled for 3pm tx tomorrow, Wed 10/11. SW called the country crisis intervention team who reported they knew pt. as they had responded to her in the past. NW staff attempted to reach pt. but left tx information on her voice mail with request she contact me and the unit to confirm her 3pm tx tomorrow. Unit SW called to report she heard from the county crisis team that stated pt. Is not in a crisis mode and left pt. with the understanding her case manager would follow up with her tomorrow.

25. SW further reported that when she attempted to speak to pt. about her tx scheduled for tomorrow, pt. yelled at her and hung up. SW requested NW staff intervene. NW staff spoke at length to pt. about her situation and at pt. request will call unit SW tomorrow to confirm tx times, transfer request to another unit that is non-Davita, and transportation. 10/11 NW staff spoke w/pt. at length to support pt. decision to receive dialysis tx today, utilize transportation provided by the unit, and follow through with her transfer request with SW. Pt. was grateful.

26. 10/27 Pt. left msg. late in the day to please call her 10/30 NW staff attempted to contact pt. Pt. answering machine provided a second number to contact pt. NW staff called and left message for pt. to call NW staff direct line. 11/1 NW staff has communicated with pt. over several phone calls and many hours. Provided pt. with information on dialysis industry to assist pt. in gaining insight into how the pt. needs to approach the system in order to get quality care. Pt. likened the dialysis “set-up” to the mental health system back in the 70’s and pt. stated she was despondent due to lack of adequate attention to the mental health of dialysis of patients in

27. general and to dialysis patients w/a mental health issues Hx. Pt. complained that because she could not get a needed prescription to treat her diarrhea and upset stomach, she had to cancel her vacation trip. She contacted the unit who first gave her a Tx time for today, then rescheduled her for her regular time tomorrow. • 11/2 NW staff called unit SW who reported pt. had Tx this morning. SW reports pt. is on her 4th transportation company and the Division of Social Services will cut her transportation benefit if she asks for another one. Pt. asked for a meeting with staff to discontinue dialysis. MD is requiring pt. have a psychiatric evaluation before the meeting; pt. agreed. Pt. asked for a list of dialysis

28. centers, counseling centers, an nephrologists who are not affiliated with the unit or the managing corporation. SW provided lists and pt. signed that she received them. NW staff spoke with pt. who reported she had changed her mind about discontinuing with dialysis. Pt. confirmed about notation. 11/6 Pt. left voice mail msg. over the weekend stating her oncologist has found her a new nephrologist and a new PC physician. Pt. stated she will find out Tues if she will be starting at another dialysis unit. Pt. stated NW staff did not need to return her call as she was just providing an update.

29. BIPOLAR DISORDER • Manic Episode • Distinct period of abnormally and persistently elevated mood at least 1 week in duration Three of the following symptoms: - inflated self-esteem or grandiosity - decreased need to sleep - pressured speech - flight of ideas or racing thoughts - distractibility

30. BIPOLAR DISORDER – CONT’D. - increase in goal-directed activity or psychomotor agitation - excessive involvement in pleasurable activities that have a high potential for painful consequences 3 Keys to approach: - Medicines - Medicine - Ear plugs

31. The spouse of a new patient has concerns regarding his “perceived” lack of communication by the renal treatment during a PD clinic appointment. The spouse feels the dialysis unit has “taken over their lives” and is irritated that the unit is “inflexible” about scheduling appointments and has even said, “We don’t change our appointments, you need to change yours.” The spouse is also upset about the renal treatment team “getting on the patient’s back and not letting the patient do things” although no specifics could be stated.

32. The spouse felt that his privacy during the spouse’s clinic appointments was violated because nurses walked in and out of the room to gather supplies needed for other patients. The spouse even began to count the number of times staff came in and out and through that “assessment” found one staff member to be the “problem”. The spouse shares concerns about his own health problems (diabetes and recent surgery) in addition to the conflict between the dialysis schedule, financial difficulties, and the clinic schedule. The housekeeper had been with them for 6 years and cannot change her days.

33. Interestingly, the spouse admitted to feeling “overwhelmed” by the demands of dialysis, which was only exacerbated by the spouse’s verbalized frustration at home and then denial of concerns at the clinic. At the clinic, the spouse felt the patient “sided” with the nurses, which in turn made the spouse feel invalidated because he is the primary caregiver and hears the complaints at home. The spouse then voiced concern that the physician didn’t refer the patient to a cardiologist. The spouse felt the physician was a young “whipper-snapper” that wants to conquer the world through his spouse and although the spouse indicated that they were going to change physicians, to date, they have not. In fact, the physician also had a

34. meeting with the family o review some of the unrealistic expectations they presented and clarified that the physician was the doctor for the patient, not the spouse’s physician. The physician also set up some boundaries, reaffirmed avenues for complaints about the nursing staff and emphasized his role as the patients’ physician. The physician even went so far as to inform the couple that he was willing to refer them to another physician or work collaboratively together, the decision was theirs and they had 10 seconds to make it. The administrator at the facility had no idea that the family was so upset or that there were

35. problems with communication or privacy. They feel they have shared realistic expectations, but are willing to try and make improvements. Questions: What do you see the problems in this situation as? Where do they stem from? How can we resolve them?

36. NARCISSISTIC PERSONALITY DISORDER A pervasive pattern of grandiosity, need for admiration, and lack of empathy, beginning by early adulthood with five of the following: - grandiose sense of self-importance - preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love - believes that he or she is “special” and can only be understood by special, high status people or institutions

37. - requires excessive admiration - has a sense of entitlement with unreasonable expectations of favorable treatment or automatic compliance with expectations - interpersonally exploitative - lack empathy - envious of others or believes others are envious of him - shows arrogant, haughty behavior or attitudes.

38. 3 Keys to approach: - Always involve in decisions - Compliment frequently - Empathy; avoid judgment

39. PEERS, BENEFITS?, STRUGGLES – • Female patient came into lobby and turned off lights because they hurt her eyes. Male patient came in later and turned lights on, due to vision problems. A tug-of-war ensued. • Altercation continued in unit with female threatening male and was “in his face.” She also called the police. • Male patient wanted to charge units. Female patient denied any culpability and would not commit to behavioral contract. • Multiple additional patients voiced safety concerns

40. - Female patient hindered multiple attempts at meeting and upon discharge hindered attempt to gain acceptance to another unit. - Ultimately, continues to dialyze in acute care.