Who Will Protect the Disruptive Dialysis Patient?

Abstract

How common is the disruptive dialysis patient? Are outpatient dialysis centers equipped to handle such patients, especially when they only use threatening words? At what point can it be said that the involuntary discharge of such patients is warranted? What happens to these patients? If they find legal representation, under what legal authority may they continue to be treated?

This Article, originally published in the American Journal of Law & Medicine, Vol. 32, p. 53, 2006, revolves around the difficult situation of a particular patient with end stage renal disease. Although this condition is fully covered by Medicare, the patient was banned from all access to dialysis care in the outpatient setting. His caregivers regarded certain comments he made as so dangerous and threatening that he was discharged from that facility, and every other facility in his geographical area. With no options in sight, a treating hospital arranged for his care in its inpatient facility. Although the treating hospital saved his life, it was an undesirable solution for both the hospital and the patient. The patient was unable to find an outpatient dialysis home despite assurances to potential facilities that his support network would participate in his care, and despite a court's finding that he presented no danger to his current caregivers. The patient's situation only improved after he received a kidney transplant.

This Article relates the challenges of representing such a client and discusses the current debate in the dialysis industry. The Centers for Medicare and Medicaid Services' then proposed Conditions for Coverage for End Stage Renal Facilities raise the question of the need for relevant regulations to be more patient-centered. The few legal cases that have been reported concerning such plaintiffs are examined. The Article concludes that private dialysis centers should not be free to dismiss their patients from care when their "disruptive" behavior may be addressed via certain accommodations by the facilities. Involuntary discharge must not occur without strict prerequisites, such as consent by the patient's treating nephrologists and documentation of efforts to resolve the situation.

Most dialysis chains are for-profit operations with health profit margins. They are situated, owing to a regular stream of Medicare funding, to maximize the talents in each of their centers in the form of interdisciplinary staff, and to face the challenges posed by the most difficult patients. The support and direction provided by the Renal Care Networks make it possible for even the most difficult patients to be treated without jeopardizing the safety of other patients and staff. No dialysis patient should receive a death sentence.

Keywords: disruptive dialysis patient, hemodialysis patients, involuntary discharge, Centers for Medicare and Medicaid Services, outpatient dialysis centers, medical ethics, legal responsibility, Conditions for Coverage for End Stage Renal Disease Facilities, End Stage Renal Disease, ESRD