A Sticky Situation: Patients’ Rights and Options Regarding Cannulation in Hemodialysis

By Ramiro Valdez, PhD


Jim walked into the dialysis clinic and, while he put what he brought with him next to his chair, looked around. He saw the charge nurse and four technicians. He had been “stuck,” or had the needle inserted into his arm, by everyone in the room and recalled that one of the technicians had done an excellent job the last time. She had hurt him very little and positioned the needles just right. This resulted in an uneventful treatment. He knew the others also, but none of them had been able to “stick” him as well.

“I Want Bobbie to Stick Me”

“I want Bobbie to stick me,” he told the technician who approached his chair.

“Bobbie’s assigned to another station today,” the technician replied. “I need to stick you.”

Jim’s jaw tightened a bit as he decided to take a stand.

“No, I insist that Bobbie stick me,” he remarked. “I know my rights, and I have the right to be stuck by the person of my choice.”

The frustrated technician looked at Jim’s determined face.

“I’ll get the charge nurse,” he said.

A “Favorite Sticker”
This scenario is perhaps repeated at countless dialysis clinics across the country every day. Anyone who has been on hemodialysis for even a few months can verify that some staff members are better than others at “sticking.”

Most patients know the results of a “bad” stick. For this reason, many patients have a “favorite sticker,” or someone who can stick without hurting the patient too much and gets it right the first time. It is common for some patients to ask for the person they consider the “best sticker” in the clinic.

But what are a dialysis patient’s rights in this regard?

A “Knack” For Sticking

“Sticking” is a lay term for cannulation, which means sticking a small tube into a body opening. Some staff members never develop this skill while others seem to have a “knack” for it. Dialysis clinics go to great lengths to teach nurses and technicians how to cannulate well, but there seems to be some staff members that will not learn the correct technique.

There is no connection between number of years working in dialysis and good cannulating. Some “older,” more experienced staff members never learn the right way to do it. Nor is there a connection between going to school and cannulating well. There are many technicians with only a few weeks of training who are better at cannulating than nurses, or even doctors, with many years of experience. Patients quickly learn who among the staff are the “good” cannulators and prefer being “stuck” by them.

Patient Cannulation “Rights”

The regulations written by the Centers for Medicare and Medicaid Services and the various state Departments of Health do not cover every aspect of the daily dialysis routine. There is no regulation anywhere that says that patients have the right to be cannulated by the staff member of their choice every time. However, the American Association of Kidney Patients (AAKP) and the National Kidney Foundation (NKF) both indirectly address the topic.

Both AAKP1 and the NKF2 cover the “rights” of all dialysis patients. These documents have been embraced by all dialysis agencies and are at the heart of all patient policies of the dialysis corporations.

“A Change in the Type of Treatment”
NKF states that patients have the right to “suggest a change in the type of treatment.”3 When a patient requests a particular staff member to cannulate him/her, it constitutes a suggestion to make a change in the treatment. Therefore, patients have the right to request a certain person to cannulate them.

The NKF Dialysis Patients’ Bill of Rights and Responsibilities also states that patients have the right to have the staff “listen” to their suggestions about their treatment.4 This means that the clinic has the obligation to attempt to comply with the patients’ requests. Therefore, if the requested staff member is available to cannulate the patient, the patient’s wishes must be heeded.

Specifically Requested Technicians
Specifically requested technicians or nurses are not always available, however. Sometimes, they are assigned to other stations, and they must attend to other patients. At other times, the requested staff member may be “off the floor,” meaning he/she is at lunch or taking a break.

Most often, the requested person may be busy putting other patients on the dialysis machine. All staff in dialysis clinics has multiple duties other than putting patients on the machine. There are times when these duties demand that staff work at something else in the clinic. Finally, the requested staff member may not wish to attend to the request, for various reasons. All of these situations may make the requested person unavailable.

Shortening Treatment?
If the requested staff member can attend to his/her duties, and within 20-30 minutes, also help the requesting patient, the patient may sit and wait those minutes for the staff member to become available. However, if a patient chooses to wait the 30 minutes or so for the requested staff member, the patient’s own treatment may have to be shortened by as many minutes.

The reason for this is because there may be another patient ready to use that same chair as soon as the requesting patient is finished with the treatment. Asking the next patient to wait and be put on the machine 30 minutes late just because of the previous patient’s wishes is not allowed. Even if the requesting patient is on the last shift and there are no other patients using the chair afterwards, he/she cannot expect the staff to stay 30 minutes overtime to comply.

It is never a good idea to shorten a patient’s treatment, and it should be done only during extreme emergencies. Asking for a particular staff member to cannulate a patient can lead to a shortened treatment… at the patient’s own request.

 Skipping a Treatment?
If the requested staff member is not available at all, the patient is faced with another choice: either be cannulated by someone else or skip a treatment. Both AAKP and the NKF state that patients have the right to accept or refuse a treatment.5,6 The patient can simply refuse to be cannulated, thereby refusing a treatment.

NKF added a warning to patients that they “accept full responsibility for the medical outcomes of your refusal.”6 The risky outcomes of skipping treatments cannot be overstated. It is in the patient’s best interest to accept the dialysis nurse or renal technician who might be available at that time to perform the cannulation.

Most often, a patient will refuse one staff member to stick him/her and request another because of a bad experience. Bad experiences are not unusual in dialysis, but no one wants to repeat them. If this is the case, perhaps the following tips may be helpful:

“A Second Chance”
Tip No. 1: Give the Staff Member a Second Chance. Everyone makes mistakes. It is hard when the mistake hurts someone else, and staff members hate it when this happens, but even the best “stickers” had to learn at one time or another.

Some patients have one bad experience and close the door to that staff member forever. This is hard on everyone. It would be better if the patient were to approach the erring staff member, tell him/her that the “bad” cannulation hurt a lot, but the patient is willing to try again with that nurse or technician. No doubt this will gain an ally for the patient. It is important to recall that staff members hate “bad sticks” as much as the patients, and they are eager to learn how to do it well.

Many “Good Stickers”
Tip No. 2: Broaden the Circle. It is unwise and impractical to have only one staff member as a favorite cannulator. Patients can be instructed by their nurse that there are many “good stickers,” and it is smart to know who they are.

If a patient knows who the “good stickers” are, but his/her first choice for cannulation is not available, there will be a second, third, or even fourth choice. This way, the patient is almost always getting what he/she wants.

Teaching and Cannulating
Tip No. 3: Teach Staff Members While They Cannulate. Even the best cannulators in the business had to learn their craft at one time or another. The best teachers they could possibly have are patients!

Like all teachers, patients must be patient, kind, and speak in a normal tone of voice. When a staff member makes a mistake, it is important that the patient not yell or fuss, but rather be firm and instructive, like a good teacher. Dialogue between patient and cannulator is an excellent way for nurses and technicians to learn what they are doing right–and wrong!

Relax and Focus
Tip No. 4: Relaxation and Guided Imagery (RGI). Some patients have tried such techniques as hypnosis or RGI to help them focus on something besides the pain. Basically, RGI is a technique anyone can learn that begins with the patient taking a deep breath and concentrating on a “safe” or “relaxing” scene. Some patients find that imagining they are taking a walk in a forest trail or lying on a deserted beach helps them ease the pain.

It takes some practice to develop this skill, but it is well worth it once it is learned. The clinic social worker may be a good resource for this technique.

Can Painkillers Help?
Tip No. 5: Topical Anesthetics. Some people have found that painkillers, either injected or sprayed, can help.

Injected painkillers can make it easier to withstand the “brief, though noticeable, pains of needle sticks at the start of dialysis.”7 Other patients have found that the injection hurts more than the cannulation, or the spray painkiller is too expensive. It is best for patients to decide for themselves after they have tried both ways.

“Fear of Injections”
Tip No. 6: Psychiatric Diagnosis. There is a psychiatric diagnosis called specific phobia with a subtype of “Blood-Injection-Injury type.”8 This phobia can be characterized by an abnormal or unusual fear of injections (among other things). This type of phobia runs in families and sometimes causes such a great fear that people actually faint at the sight of a hypodermic needle.

Patients who believe they may have this phobia should discuss it with their doctor and request a referral to a psychiatrist. There are several medicines that can help.

Self-Stick Patients
Tip No. 7: Self-Cannulating. No one can “stick” patients as well as they can “stick” themselves. Medicare regulations, as well as those of most state Departments of Health, allow patients to self-cannulate. The very thought is discomforting for some patients, but, with a little practice, they can become very good at it. This is especially true of insulin-dependent patients who have been giving themselves injections for several years.

Those people who wish to self-cannulate will need to be trained and observed every time by a staff member.

The late Peter Lundin, MD–dialysis patient, nephrologist, and past AAKP President–said: “Putting in your own needles is the best guarantee for a sure stick and less pain.”9

As long as dialysis treatments involve cannulating, there will be “good” stickers and “bad,” or “not so good,” stickers in every clinic. Rather than shorten or skip a treatment, patients can give staff members a second chance and even become teachers of the “bad stickers” by letting them know how they are doing during the cannulation process.

There are also a variety of different things that patients could do to help themselves cope with the pain of cannulation. Patients and staff can work together and help each other in what, despite all our medical and technological advances, continues to be a constantly evolving art in medical care.

American Association of Kidney Patients, AAKP Patient Plan, Phase 1, AAKP: 2003. For more information, log onto the AAKP website at: www.aakp.org.

National Kidney Foundation. Dialysis Patients’ Bill of Rights and Responsibilities. New York: NKF: 2003. For more information, log onto: www.kidney.org.

Weiss, J. Is Dialysis Painful? AAKP RenaLife, Vol. 14, No.2, September, 2003.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, 1994.

Lundin, P. How Can I Better Ensure My Safety in the Dialysis Unit? AAKP RenaLife, Vol. 16, No. 4, January, 2001.

How to Deal with Difficult Staff - Kidney talk - A STICKY SITUATIONAbout the Author

Ramiro Valdez, PhD, is a Psychosocial Services Consultant who runs Valdez Seminars in Dallas, TX. Previously, he was Director of Patient Services for the End-Stage Renal Disease (ESRD) Network of Texas. He has nearly 25 years experience in the end-stage renal disease field and is the author of over 30 articles in renal journals and magazines. For more information, log onto: www.valdezseminars.com.

Article uploaded 1-10-2007

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