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Tuesday, February 07, 2012


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Do these two patients really have "an unbroken will to live"? How do you know? Maybe their families are guilting them into perservering with this abominable treatment. Maybe their spouses would prefer to have them live this way (do their families/spouses have any idea of the pain these patients experience? Did you see any family members around?) than to let them go to God. Or maybe their nephrologists don't take the time to discuss end of life arrangements or hospice care.

Peter Laird, MD

Dear Moosemom, only they could truly answer that question, but I do believe it is a true statement first of based on what I know about my dialysis program and the mandated updates to living wills and other documents that are required. In addition, this is a hospital based dialysis center that goes by the rules of hospital patients which is a stricter level than the free standing dialysis clinics. I can categorically dismiss the speculation that they don't get excellent counseling on end of life issues.

In addition, the man to my right appeared to be prepared for his suffering during dialysis. I must confess that I doubt seriously that I would persevere under such circumstances but I do believe that even in this type of suffering the will live is stronger for many people.

I cannot speak about the mental status of the lady to my left, but the man to my right did appear to have more control of his faculties. Since I didn't interview either of them for obvious reasons, there is always the speculation of the statement, but it was my impression that the man biting down on the cloth during the latter stages of his dialysis did so with complete preparation for what was to come. That in itself does imply the ability to still choose.

In any case, I have seen many patients suffer through terrible circumstances with a raging will to survive. I believe that is what I was witnessing again.

The real issue of this post is not so much why these people were suffering, but instead the complete disregard of their suffering by the staff. It was really striking since I have seen other units that were more responsive. It was difficult to watch the lack of care shown. As a doctor, I know I would not have ignored such suffering. It just strikes to the core of your heart.


I understand the purpose of your post. Did you consider saying something to the staff about what you were witnessing? I am afraid I would not have been able to keepsilent,

Peter Laird, MD

Actually, I decided to write a post available nationwide on the issue since it is not only this single unit that this is a problem. I know folks at my unit read my blog, so I believe that I have done the proper notification.


But what made you stay silent in the presence of these particular trees in this particular forest on this particular day?

Peter Laird, MD

Dear Moosemom, if you wish me to go into a treatise on changing things at Kaiser with its powerful unions, no problem. Since it wasn't just a single person, but a pervasive problem I have seen in so many other units as well, your criticism is actually quite out of place in my opinion. As you see, I was not silent was I.

I have found great response to public criticism of an industry. I could but won't give you many examples of how that has been effective as it was for Bill Peckham as well. Indeed, Bill Peckham sat on the TEP a couple of years ago as the only non-health professional dialysis expert. And I would add, he more than held his own.

We all pick our battles. Can you really indeed state I was silent on this issue that has reached thousands of people? Who says I am done?


Dear Peter, you are missing the point of my question. The work you and Bill have done in the past is not in question.

I am not sure how calling attention to the suffering of two dialysis patients is a "battle". I am not saying you have been silent on this issue, but you were silent on that day, and I'd like to know why. Perhaps you felt unwell. Perhaps you were reluctant to cause a fuss. Perhaps you didn't want to imply criticism.

I believe that the revolution starts with us. I know I don't have to tell you that it is up to us to stand up for ourselves AND for our fellow patients whose voices may not be as loud.

I sure hope you are not done!

God Bless,


PS...I'll take this opportunity to thank you publically for all the advocating you have done on behalf of renal patients. I truly do appreciate your efforts and look forward to the fruits of your labors. May God truly bless you and give you the strength and will to continue in your important work. You and Bill make a formidable team.

Peter Laird, MD

It is a battle in a very real sense. I have learned that the many times I spoke up in my first dialysis unit, retaliation always comes next in one form or another. You pick your battles carefully and with tactics in mind literally when you enter the arena of American dialysis. I will bring up the issue with my nephrologist who runs the unit at my next monthly visit.

Thank you for all that you do. Prepare for your own battles that are all to soon to come as well MooseMom. I believe you already have but be diligent so that you don't stand before mean men.

Bill Peckham

You do you have to pick your battles.

As for me I've been taking a break. After many years of engagement I just see the same discussions happening again and again, and frankly I feel disappointed in the entities we call the CKD industry, including the non profits and patients groups. It's like a Möbius loop of advocacy.

Coming soon: shorter runs because hemodiafiltration does such a great job - sigh.

Carry on Peter, I'm on hiatus.

Peter Laird, MD

Bill, I look forward to the day we can both tag team them once again. At least I have escaped your red pencil.

I am actually a little more hopeful than a couple of years ago, but we will have to wait and see how the market forces shape the dialysis of tomorrow. There may be hope and yes, it is very difficult as you know to write something that you or others haven't already written. However, it won't happen until CMS positions payments tied to incentives for keeping people out of the hospital. There is a huge amount of money that could be saved by the entire system that goes uncollected every year. Worse, is the number of people that could still be alive that aren't.

Bill Peckham

I would say that payment is aligned now; it is the providers who are not taking advantage of the opportunities to provide higher doses of dialysis and thereby save Part A spending.

And Peter I wouldn't want people to think that your characterization of my TEP experience is based on my report, because that is not how I remember it. I remember being deeply over my head.

Peter Laird, MD

So was everyone else in the room, they just didn't let on. LOL.

Roberta Mikles BA RN

However, it won't happen until CMS positions payments tied to incentives for keeping people out of the hospital. There is a huge amount of money that could be saved by the entire system that goes uncollected every year. Worse, is the number of people that could still be alive that aren't.

Peter, your above statement is so very true. I have been, for seven years, trying to get someone to look at the incenter care which results in hospitalizations and deaths....and, yes, if there was tied payments to incidents that cause hospitalizations, etc., perhaps things would be different.
Roberta Mikles


I've been wondering where you've been, Bill. Where's "hiatus"? Sounds restful

Bill Peckham

The nature of the bundle means there is an incentive now to keep people out of the hospital.

If dialyzors are hospitalized then units don't get fully reimbursed for services such as monthly lab testing and the administrattion of iron.

Peter Laird, MD

Dear Moosemom, I believe Bill is planning his next world cruise to Antarctica and South America to become the first person to dialyze on seven continents. Five down, two to go!!

Roberta mikles

Unless staff are really educated and trained, mistakes will continue that result in hospital admissions
Roberta Mikles


Peter, Roberta & Bill:

Thanks so much for saving my sanity. I'm an NP with an MPH who was a research dietitian. I starting helping an HD unit affliated with a tier one University. Unfortunately it got to be too much because of the for profit momentum and I left.

There were arguments regarding staffing for RNs, MSWs & the conditions for our techs. The for profits have made their lives difficult & they are incentivized to " sign patients up" for affiliate pharmacies. Of course, they now have less pharmacists monitoring patients as well.

I just heard a speaker on Medicare fraud this weekend. According to Dr. Sheetz, the majority of fraud comes from the for profits. That includes proprietary HD, hospice, hospitals and SNIFs.

If you have ideas that could improve Medicare oversight for these areas, please let me know. My email is kheffe50@gmail.com. In addition Peter, have you considered testifying to the RPA?

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