To the Editor:
Advanced chronic kidney disease (ACKD) consultations have several objectives, such as promoting self-care and patient autonomy, preserving renal function for as long as possible, and minimising associated comorbidities. This process also attempts to establish proper communication and facilitate shared decision making regarding the different options for renal replacement therapy (RRT).1,2 This creates a particularly complex and challenging scenario for both the patient and health care professionals.
In light of this complexity, the ACKD unit of the nephrology department at the La Paz University Hospital has established a strategy in which the hospital psychologist may be present during the initial ACKD nurse’s consultation. This interdisciplinary protocol is only applied to patients that fit a certain profile, where the simultaneous intervention may facilitate adopting future treatments at the lowest emotional cost possible. These patients have been previously identified by the nephrologist and/or nursing staff as exhibiting an intense emotional state or denial attitude that might hinder the reception of important information regarding the disease and subsequent process of shared decision making.
Given that the presence of a psychologist in these consultations is not common in nephrology departments in Spain, we sought in this publication to describe the functions and objectives of psychologists within this treatment strategy, as well as to present our treatment protocol.
This editorial was sent for publication to the journals led by the two scientific societies involved in our area of medicine (Spanish Society of Nephrology and Spanish Society of Nephrological Nursing), with the objective of reminding us that, in the integrated approach to treating renal patients, there is far more that unites us than that divides us.
1. FUNCTION AND OBJECTIVES OF THE PSYCHOLOGIST IN ACKD NURSING CONSULTATIONS
The primary function of the psychologist in ACKD nursing consultations is to support the nursing staff in the process of communication and shared decision making. The primary objectives include:
- Detection of possible difficulties that the patient may have in understanding the information provided. If such a difficulty is detected, the psychologist may help regulate the passage of information from the nursing staff so that it adjusts to the patient’s cognitive rhythm, to clarify content, and to aid the patient in articulating doubts.
- To evaluate the patient’s emotional state during the process of information communication. The psychologist will be attentive to the patient’s non-verbal communication so as to evaluate whether his/her emotional state is appropriate to continue receiving information, or whether the patient needs to stop and continue later.
- To reinforce the nursing staff in facilitating the provision of emotional support to the patient. “Emotional support” in this case is the creation of a therapeutic relationship in which the patient does not feel judged, but rather understood and assisted in order to confront his/her doubts, needs, and desires in an environment of mutual respect.
- To support the nursing staff in exploring the values and lifestyle of the patient for the sake of facilitating shared decision-making. The available literature informs us that there is no single dialysis technique that is better per se, but rather that the criteria for choosing one type of treatment or another must be based on the patient’s lifestyle and value system, among other variables.3
- To intervene in moments of crisis involving difficult communication with the patient, in the case that the patient exhibits intense emotional reactions that are complicated to manage (sadness, anxiety, hostility, etc.).
- To include family members in the communication process by asking open and focused questions.
In addition to the aforementioned aspects of patient care, the presence of the psychologist in these consultations facilitates the patient undergoing psychological evaluations and interventions for specific needs when appropriate.
2. JOINT NURSING-PSYCHOLOGIST PROTOCOL FOR ACKD CONSULTATIONS
This nursing-psychologist consultation is only activated through referral from the nephrologist caring for each patient, who is charged with leading the communication and shared decision making process for RRT options. At each step of the process, we indicate the type of health care professional who can provide the best input, based on the notion that in all consultations, the task of providing optimal patient care is a coordinated effort.
Despite the fact that we have had the opportunity to observe the benefits of this joint protocol, the presence of the psychologist in the ACKD consultation is not a common occurrence, and requires training for both the psychologist and nursing staff. It is essential that the psychologist understands the basic medical and nursing care aspects for patients with ACKD in order to provide useful support in this process. It is also essential that the nurse receives information regarding therapeutic communication skills.
Nephrology in the XXI century must involve creating interdisciplinary teams for the treatment of ACKD, as well as an integrated bio-psycho-social approach to the disease.5 We propose going even farther: we take on the challenge of creating scenarios of joint intervention on patients health, in which intervention strategies are different and the objectives are complementary, in order to promote greater satisfaction for renal patients and their family members, as well as for the health care professionals that look after them.
Acknowledgements
We would like to thank our patients and their families for pushing us every day to take on new challenges in health care.
We would also like to thank Almudena Perez-Torres for reminding us for almost four years of the importance of teamwork as an element of defence against patient suffering.
Conflicts of interest
The authors declare that they have no conflicts of interest related to the contents of this article.
