What is the best management plan for an elderly female patient with ESRD, multiple comorbidities, and noncompliance with dialysis, considering her complex medication regimen and history of smoking?

Case Management Recommendations for ESRD Patient with Dialysis Noncompliance

This patient requires immediate implementation of a multidisciplinary care coordination team with mandatory monthly medication reconciliation, structured transportation assistance, and consideration for assisted living placement given her repeated hospitalizations and inability to maintain dialysis adherence. 1

Immediate Medication Safety Interventions

Implement formal medication reconciliation within 7 days to identify and resolve the 2-3 medication discrepancies statistically expected in this ESRD patient with polypharmacy (currently on 13 medications). 1

Critical Medication Review Points:

• Discontinue or adjust losartan and amlodipine - ACE inhibitors/ARBs and calcium channel blockers require careful dose adjustment in ESRD patients due to altered pharmacokinetics and increased risk of hypotension during dialysis. 1
• Verify sevelamer carbonate dosing - Current 800 mg dose must be taken separately from ciprofloxacin (2 hours before or 6 hours after) and mycophenolate (2 hours before). 2 Document if patient is actually taking these medications as prescribed.
• Assess for fat-soluble vitamin deficiency - Sevelamer binds bile acids and reduces absorption of vitamins A, D, and K; current ergocalciferol 50,000 units may be insufficient. 2
• Review metoprolol 100 mg - No dose adjustment needed per FDA labeling, but monitor for excessive bradycardia (current pulse 64). 2

Medication Reconciliation Process:

• Designate a renal pharmacist or registered nurse to perform monthly reconciliation as required by Medicare QIP starting 2022. 1
• Obtain medication lists from all sources: patient/caregiver "brown bag" review, pharmacy records (Surescripts), recent hospital discharge summaries. 1
• Document four discrepancy types: medications no longer taken, not in record, dosing issues, and direction issues. 1

Dialysis Adherence Strategy

Establish mandatory transportation coordination through the dialysis unit social worker with backup plans for missed appointments. 1

Structured Intervention Plan:

• Schedule fixed transportation with the dialysis center's contracted service, not relying on patient to arrange rides. 1
• Implement same-day contact protocol - Designate specific staff to call patient within 2 hours of any missed dialysis session. 1
• Document barriers at each visit: physical limitations (wheelchair-bound due to spinal stenosis), cognitive factors (encephalopathy history), social support deficits. 1, 3

Home Dialysis Reconsideration:

• Address smoking cessation as prerequisite for peritoneal dialysis eligibility - refer to pulmonary rehabilitation given chronic respiratory failure with hypoxia on 3L O2. 4
• If patient achieves smoking cessation, peritoneal dialysis offers home-based option reducing transportation barriers. 4

Care Coordination and Higher Level of Care Assessment

Convene interdisciplinary team meeting within 14 days including nephrology, primary care, social work, case management, and family to reassess living situation. 1

Team Assessment Priorities:

• Functional capacity evaluation - Patient is wheelchair-bound, requires assistance with IADLs, has spinal stenosis with pathologic thoracic fracture limiting mobility. 1, 5
• Cognitive assessment - History of encephalopathy warrants formal evaluation for decision-making capacity and medication self-management ability. 1
• Social support inventory - Living alone with four hospitalizations in 2 months indicates inadequate support structure. 1

Placement Options to Consider:

• Assisted living facility with dialysis transportation - Provides medication supervision, meal preparation, and coordinated medical transport. 1
• Skilled nursing facility - If functional decline continues or dialysis adherence remains poor despite interventions. 1
• Enhanced home services - Daily home health aide visits for medication administration and vital sign monitoring if patient refuses facility placement. 1

Goals of Care Discussion

Initiate serious illness conversation within 30 days to align treatment intensity with patient preferences, given 40% first-year mortality risk for patients >75 on dialysis. 3

Conversation Framework:

• Explore patient's understanding of ESRD prognosis and treatment burden (average 2 hospitalizations/year for ESRD patients). 1, 3
• Assess quality of life priorities - Does she value independence over life prolongation? What functional abilities matter most? 1, 3
• Discuss palliative care option - Conservative management without dialysis is reasonable alternative for patients with limited life expectancy or severe comorbidities (elevated troponin, pulmonary edema, chronic respiratory failure). 6, 3
• Document advance directives - Code status, healthcare proxy, preferences for hospitalization vs. comfort care. 7, 3

If Patient Chooses to Continue Dialysis:

• Establish measurable adherence goals - Attend ≥90% of scheduled dialysis sessions over next 3 months. 1
• Define triggers for palliative care referral - Further functional decline, additional hospitalizations, or patient request. 7, 3

If Patient Chooses Conservative Management:

• Initiate hospice referral - ESRD patients declining dialysis meet Medicare hospice eligibility criteria. 7
• Optimize symptom management - Focus on dyspnea control (current 3L O2 requirement), volume management, uremic symptom palliation. 7, 6

Monitoring and Reassessment Schedule

Establish structured follow-up intervals with clear accountability for each care transition. 1

• Weekly dialysis unit check-ins - Document attendance, vital signs (current BP 146/76 requires monitoring), weight, symptoms. 1
• Monthly medication reconciliation - Required by Medicare QIP for all dialysis patients. 1
• Quarterly interdisciplinary team review - Reassess functional status, adherence patterns, living situation adequacy. 1
• Post-hospitalization contact within 24 hours - Verify medication changes, schedule follow-up appointments, assess home safety. 1

Critical Safety Considerations

High-Risk Medication Monitoring:

• Avoid prescribing cascade - Do not add medications to treat side effects of existing drugs without full medication review. 1, 8
• Minimize sedating medications - Patient already wheelchair-bound with fall risk; avoid adding benzodiazepines or high-dose opioids. 8
• Monitor for drug-drug interactions - Particularly with clopidogrel, warfarin if added, and any new antibiotics. 2

Volume Status Management:

• Current exam shows no edema despite recent pulmonary edema hospitalization - indicates adequate current dialysis when attended. 9
• BP 146/76 acceptable for dialysis patient; aggressive BP lowering increases mortality risk. 6, 9
• Maintain 3L O2 for chronic respiratory failure; do not reduce without pulmonary consultation. 6

Red Flags Requiring Immediate Intervention:

• Missed ≥2 consecutive dialysis sessions - Triggers emergency contact and possible involuntary hospitalization evaluation. 3
• New chest pain or dyspnea - Given elevated troponin history and cardiovascular medication regimen. 1
• Altered mental status - May indicate uremia, medication toxicity, or electrolyte derangement. 1