title: Management of ethical issues related to care of seriously ill dialysis patients in free-standing facilities.
abstract: BACKGROUND
  There are few data on the frequency and current management of clinical ethical issues related to care of seriously ill dialysis patients in free-standing dialysis facilities.
  
  
  OBJECTIVE
  To examine the extent of clinical ethical challenges experienced by care providers in free-standing facilities and their perceptions about how those issues are managed.
  
  
  METHODS
  A total of 183 care providers recruited from 15 facilities in North Carolina completed a survey regarding the occurrence and management of ethical issues in the past year. Care plan meetings were observed at four of the facilities for three consecutive months. Also, current policies and procedures at each of the facilities were reviewed.
  
  
  RESULTS
  The two most frequently experienced challenges involved dialyzing frail patients with multiple comorbidities and caring for disruptive/difficult patients. The most common ways of managing ethical issues were discussions in care plan meetings (n = 47) or discussions with the clinic manager (n = 47). Although policies were in place to guide management of some of the challenges, respondents were often not aware of those policies. Also, although participants reported that ethical issues related to dialyzing undocumented immigrants were fairly common, no facility had a policy for managing this challenge. Participants suggested that all staff obtain training in clinical ethics and communication skills, facilities develop ethics teams, and there be clear policies to guide management of ethical challenges.
  
  
  CONCLUSIONS
  The scope of ethical challenges was extensive, how these challenges were managed varied widely, and there were limited resources for assistance. Multifaceted efforts, encompassing endeavors at the individual, facility, organization, and national levels, are needed to support staff in improving the management of ethical challenges in dialysis facilities.
authors.affiliation: School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. Electronic address: songm@email.unc.edu.
authors.forename: Mi-Kyung
authors.initials: MK
authors.lastname: Song
authors.affiliation: School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: Laura C
authors.initials: LC
authors.lastname: Hanson
authors.affiliation: UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: Constance A
authors.initials: CA
authors.lastname: Gilet
authors.affiliation: School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: Minjeong
authors.initials: M
authors.lastname: Jo
authors.affiliation: School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: Teresa J
authors.initials: TJ
authors.lastname: Reed
authors.affiliation: School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: Gerald A
authors.initials: GA
authors.lastname: Hladik
mesh_terms: D000328:Adult; D000368:Aged; D000554:Ambulatory Care Facilities / Q000941:ethics*; D026690:Ethics, Clinical; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009657:North Carolina; D006435:Renal Dialysis / Q000941:ethics*; D055815:Young Adult
keywords: Ethical issues; renal dialysis units