Megan R. Prescott, MSW, LCSW University of Colorado Hospital Joseph R. Merighi, MSW, PhD

1. ManagingProblematic Patient Situations in the Dialysis Treatment Environment: A Team Approach to Creating Partnerships Megan R. Prescott, MSW, LCSW University of Colorado Hospital Joseph R. Merighi, MSW, PhD Boston University School of Social Work

2. Agenda • Identify most difficult challenges in responding to mental illness • Strategies for managing these challenges • Tips and suggestions for managing most common mental illnesses • Questions and summary

3. Most Challenging Cases • Cases from your experience • Prevalent diagnosis? • Challenges unique to the dialysis setting? • Other common denominators?

4. Introduction • The size of our populations guarantees the presence of mental illness • Challenges of working with mental illness in the dialysis facility • Mental illness as a co-morbid condition • Staff is unprepared to respond

5. Introduction • The importance of a Team Approach to managing mental illness • The unique role of the social worker • Visibility of social work training and skills in day-to-day dialysis facility operations

6. Prevalence of Mental Illness • Average facility size • Unique population • Co-morbid conditions • Personality disorders • Addiction

7. Staff is Unprepared to Respond to Mental Illness • Little to no training in mental health issues • Emotional responses to signs and symptoms • Lack of time • Long hours, task redundancy

8. Challenges of the Dialysis Environment • Rigidity • Lack of privacy • Staff is unprepared for mental illness • Treatments can be physically taxing and stress inducing

9. The Team Approach • Coordinating the effectiveness of the team’s roles and skills • Predictability of team response • Consistency • Broader support for patients with mental health issues

10. The Most Common Diagnoses • Depression • Anxiety • Dementia • Personality Disorders • Addiction?

11. Bringing Mental Illness to Care Planning • An opportunity to discuss SW assessment with MD, Nurse and Dietician • MD can prescribe when appropriate • Dietician can review how mental illness (depression) is affecting outcomes • Nurse can bring observations in care planning back to involved staff

12. Depression • The most common diagnosis in the general population as well as the ESRD setting • Symptoms affect response to treatment • Staff reactions to symptoms • Treatment in the dialysis facility? • Affect on outcomes • Poor appetite • Sleep loss • Low motivation • Hopelessness

13. Staff Response to Depressive Symptoms • Anger • Fear • Sadness • Disgust • Frustration

14. Managing Depression • Staff training and support to manage emotional reactions • Consistent and compassionate support for non-adherence • Avoid pressure to change non-adherent behaviors • Encourage re-engagement in pleasurable activities and social networks

15. Anxiety • Rigidity of dialysis environment • Anxiety reactions in patients can be particularly challenging for staff • Rehearse responses to “routine” situations

16. Managing Anxiety • Take time to explain changes in schedule, seating assignment • Consider seating changes to reduce exposure to anxiety provoking situations. • Offer choices whenever possible • Consistent and compassionate response to outbursts

17. Dementia • Increasing incidence in dialysis population • Staff response • Staff demands • Danger to patient/staff/other patients

18. Managing Dementia • Communicate with caregivers • Routinize care • Rotate staff • Practice patience • Distraction

19. Personality Disorders • Challenges of constant, pervasive patterns will test staff • SW support to ease staff stress and increase understanding • There are ten, some are more challenging than others in the dialysis setting

20. Managing Personality Disorders • Staff training • Role play and dialog rehearsal • Avoid labels • Help staff understand the limits of capacity for change • Day by day, situation by situation

21. Addiction • Underlying cause? • Sings of withdrawal from different substances • Understanding the effects of drugs on the dialysis patient

22. Managing Addiction • Risk management • Missed treatments • Encouraging more functional coping strategies • Resources for recovery as appropriate

23. Team Approach to Managing Mental Illness in the Dialysis Environment: DEPRESSIONBy Megan Prescott, LCSW • While depression is likely the most common mental disorder occurring in dialysis patients (as much as 44% suffer from depression at some point while being treated with dialysis), it is important to recognize that depression in dialysis patients is not normal, has a negative impact on outcomes, and is treatable. • Carefully assess to differentiate from uremia (cognitive vs. somatic symptoms) • Support and educate staff to recognize and respond effectively to signs and symptoms of depression to improve comfort, build professional relationships and improve outcomes • Assess for clinical risk • Psycho-education to normalize the experience, help patients understand their symptoms and the potential of therapies to help them feel better

24. Team Approach to Managing Mental Illness in the Dialysis Environment: DEPRESSIONBy Megan Prescott, LCSW • Consult with MD (or encourage patient to see PCP) for medication evaluation. • For patients who start medication, support and screen for several weeks to ensure proper dosing and monitor for side effects that may lead to patient discontinuing medication. Educate regarding time frame for clinical results, so patients don’t abandon medication early for lack of symptom remission. • Listening support can be helpful! • Cognitive behavioral techniques can be used briefly in clinical environment. • Model compassionate support for staff rather than pressure to change • Explore support sources available to patients, even those that they are not taking advantage of. • Encourage patients to complete an activity log to increase activities • Consider a depression support group or class in center

25. Team Approach to Managing Mental Illness in the Dialysis Environment: ANXIETYBy Megan Prescott, LCSW • There are a variety of disorders we can see in this category, including panic, PTSD, OCD, phobias and GAD • Take time to explain changes in schedule, seating, or any other part of the patient’s routine. • Offer choices whenever possible to help patients maintain some sense of control • Consider seating changes to reduce anxiety provoking situations, and avoid seating anxious patients in close proximity • Panic attacks can be dangerous if the patient cannot resist the urge to stay in their chair while they are hooked up. It can be helpful to teach self-calming or relaxation techniques, and help patients identify triggers.

26. Team Approach to Managing Mental Illness in the Dialysis Environment: ANXIETYBy Megan Prescott, LCSW • For patients who have patterned or “routine” reactions, it can be helpful to rehearse responses and even practice or role-play, so staff has a prepared response. • Make sure staff responses to outbursts are consistent and compassionate to avoid damaging the professional relationship and heightening a patients sense of shame around losing control • Claustrophobia can be eased by seating near a window or with a clear view of the exit. Avoid corners. • Needle phobia can be helped with emla cream, lidocaine, distraction, and relaxation techniques such as deep breathing.

27. Team Approach to Managing Mental Illness in the Dialysis Environment: DEMENTIABy Megan Prescott, LCSW • Stay in close contact with caregivers to communicate important treatment information, consider a treatment notebook that goes back and forth between clinic and home for easy communication of changes • Communicate directly with patient even thought they may not be likely to remember or understand all of what you are telling them to enhance self esteem and keep patient engaged in treatment process. • Support staff in situations where patients are overly demanding of time and attention with frequent rotation • Routinize patient care with all staff and practice a script to respond to redundant patient questions to reduce anxiety, confusion and agitation

28. Team Approach to Managing Mental Illness in the Dialysis Environment: DEMENTIABy Megan Prescott, LCSW • For patients at risk of pulling needles due to a combination of boredom, confusion and agitation, ask family to send or hire a sitter to stay with patient throughout treatment • Try distractions that occupy patient’s hands, such as puzzle boards, toys, dolls, lollipops, etc. • Process staff’s emotional responses to family’s decision to keep patient with advanced stages of dementia on dialysis even when it requires a high level of management. • Help family process the decision to continue dialysis (as appropriate)

29. Team Approach to Managing Mental Illness in the Dialysis Environment: PERSONALITY DISORDERSBy Megan Prescott, LCSW • Help staff understand the limited potential for profound change • Help staff rehearse ways of responding to patient behavior day to day and situation to situation • Avoid labeling patient with suspected diagnosis with staff • Don’t argue or engage drama patterns • Stay neutral • Watch for splitting • Seek consultation from other SWs to manage your own responses and feelings

30. Team Approach to Managing Mental Illness in the Dialysis Environment: ADDICTIONBy Megan Prescott, LCSW • Help staff understand the cognitive and behavioral manifestations of substance abuse • Avoid labeling the patient • Carefully assess presenting symptoms to differentiate from other mental health diagnoses • Seek consultation from MD and SW to help connect patient with support services in the community

31. Create an Online Mental Health Toolkit for Dialysis Professionals • Identify key resources that will • Educate members of the dialysis treatment team about mental illness • Support patients with mental illness and their family members • Website design for Mental Health Toolkit • Resources by state and county • Resources by mental health diagnosis • Resources by type of service

32. Conclusion • Critical links in managing mental illness in the dialysis treatment environment include: • The Dialysis Team • The Social Work Team • The ESRD Network Team

33. Questions? megan.prescott@uch.edu merighi@bu.edu