Exploration of Factors That Impact Mode of Death in Hemodialysis Patients.

Research Critique

The investigator used both a quantitative and qualitative design to examine factors that might influence the unintentional or intentional mode of death in hemodialysis patients. The findings revealed that though demographic, social integration, role change, and social support factors did not differ significantly between the unintentional death and intentional death patient groups, patients who experienced a rapid, downward spiraling illness trajectory were more likely to withdraw from dialysis and die an "intentional" death compared to patients who experienced a fairly slow downward trend in their illness trajectory. Although it is not surprising that patients or loved ones chose to end chronic dialysis treatments when experiencing a persistently declining illness trajectory, this investigation certainly lays the groundwork for nurses to gain a better understanding of hemodialysis patients' chronic illness experience and factors that might influence their mode of death.

The quantitative data analysis included a retrospective review of deceased hemodialysis patients' medical records for cause of death. To examine social support, social integration, and role change factors that might influence mode of death, 32 significant others of deceased patients were asked to complete three self-report instruments. For two of the instruments, the Social Integration tool and the Role Change tool, the patients were the instruments' unit of analysis. This means that the instruments were designed to measure the patients' perception of their social integration and participation in social roles. For this study, the investigator sought this information from a secondary source, the significant others of patients. Their responses to these instruments served as "proxy" responses for the deceased patient. Thus, participants were asked to "recall" potentially distant experiences for someone else, an inherent weakness of the study. The deaths occurred between 1990 and 1994. How long after the deaths were the significant others interviewed?

The investigator also reported that two of the instruments had no established reliability and validity, nor were any of the instruments' reliability and validity reported for this study. Why not? Clinicians should always assess the quality and adequacy of the research instruments when reading a research report. The reliability and validity of research instruments are criteria that serve as indicators that the tools accurately and validly measure the study phenomena of interest (for this study -- social support, social integration, role change). If instruments are not reported as reliable and valid, it becomes difficult to make valid and reliable conclusions regarding data that these instruments generate.

Findings from the qualitative analysis certainly contribute an important perspective regarding patients' and loved ones' ESRD illness experiences. Though patients' illness trajectory was explored through the thoughts of significant others, the illness experience descriptions should raise the consciousness of nurses in clinical practice regarding patients and their loved ones' level of awareness of the seriousness of the ESRD, its treatment, and the potential impact of the illness on their lives. These findings suggest that nurses who have contact with patients and families prior to the initiation of chronic renal replacement therapy should explore further the level of ...