Special Situations and Shared

The contract between this chapter and the reader.

1. 1. Identify the special situations in PD and their key considerations.
2. 2. Determine when assisted PD extends access to home dialysis.
3. 3. Apply a frailty- and goals-based assessment to modality choice.
4. 4. Set up urgent-start PD safely as an alternative to a central venous catheter.
5. 5. Explain the rationale and limits of a PD-first policy.
6. 6. Distinguish effective-care decisions from preference-sensitive decisions.
7. 7. Recognise PD versus conservative (non-dialysis) care as a genuine values-driven choice.
8. 8. Conduct a shared-decision conversation using natural-frequency framing and teach-back.
9. 9. Approach dialysis withdrawal and end-of-life transitions in PD.

A sixty-second reading. Each bullet stands alone.

• Special situations in PD include assisted PD, the frail or elderly patient, urgent-start, PD-first policy, transplant bridging, and conservative care.
• Assisted PD lets patients who cannot self-care keep home dialysis with a trained carer or visiting nurse.
• For frail older patients, modality choice turns on goals, burden, and helper availability — assessed comprehensively, not by age alone.
• Urgent-start PD begins within days of insertion using low-volume supine exchanges, avoiding a central venous catheter and its risks.
• A PD-first policy preserves residual function, vascular access, and home autonomy where PD is suitable.
• Effective-care decisions are settled by physiology and evidence; preference-sensitive decisions are settled by the patient's values.
• The most important preference-sensitive decision is whether to dialyse at all, especially in frail elderly with limited prognosis.
• In that group, dialysis may not extend good-quality life, and conservative care is a legitimate path, not a failure.
• Shared decision-making runs choice talk, option talk with natural-frequency numbers, and decision talk, closed with teach-back.
• Decisions are documented with the patient's values and revisited as circumstances change.
• Withdrawal of dialysis is a planned, palliative transition when PD no longer meets the patient's goals.
• Family and carers are part of the conversation, especially around assisted PD and conservative care.

The medical core. An expert should agree the special situations and the decision framework are fully covered here.

Why it matters at the bedside

Most of this book decides what the membrane needs. This chapter decides what the person wants. The hardest questions in PD — whether to dialyse at all, which modality, who helps, and when to stop — have no physiological answer; they are settled by the patient's values, and the clinician's job is to make that choice a real and informed one.

The special situations, in brief

• Several situations sit outside the routine prescription: patients who cannot self-care, frail older patients weighing whether dialysis serves their goals, those needing dialysis urgently without time to prepare, programmes deciding which modality to offer first, and patients for whom not dialysing is the better path. Each blends a practical setup with a values question.

Assisted PD

• Inability to perform exchanges alone is not inability to do PD. A trained family member or visiting nurse can perform or supervise exchanges and exit-site care, keeping frail, cognitively impaired, or visually impaired patients on the home therapy they prefer rather than defaulting them to in-centre haemodialysis.

The frail and elderly patient

• Age alone is a poor guide. A comprehensive assessment of frailty, function, goals, and helper availability does the work: PD can suit older patients — home-based, gentle on the circulation, no vascular access — but the burden on patient and carer must be weighed, and for some the right answer is haemodialysis or conservative care.

Urgent-start PD

• When a patient needs dialysis before a catheter can heal, urgent-start PD uses low-volume supine exchanges from within days of insertion, increasing gradually to limit leak (Chapter 4). It spares the patient a central venous catheter and the bloodstream infection and thrombosis that come with it.

PD-first policy

• Offering PD as the initial modality where suitable preserves residual function, leaves the vasculature intact for future access, and supports home autonomy. It is a programme-level stance, applied patient by patient, not a mandate that overrides individual values.

Transplant bridging

• For transplant-eligible patients, PD bridges well to transplantation. In long-duration patients the conversation includes EPS risk and its triggers (Chapter 8), since stopping PD and transplantation can both set it off.

Effective-care versus preference-sensitive decisions

• The organising distinction of this chapter: some decisions are effective-care, where physiology or evidence dictates the answer — low-volume supine exchanges in urgent-start, glucose-sparing, matching dwell to transport. Others are preference-sensitive, where reasonable people choose differently based on what they value — modality, dialysis versus conservative care, continuing versus stopping.
• Naming which kind of decision is in front of you settles who should decide: the clinician leads effective-care, the patient leads preference-sensitive, and confusing the two either overrides values or abandons patients to choices that have a right answer.

PD versus conservative care

• For frail elderly patients with limited prognosis or heavy comorbidity, dialysis may add little good-quality time while adding hospital days and treatment burden. Conservative kidney management — active symptom control without dialysis — is a legitimate, evidence-informed choice, and presenting it honestly is part of good care, not a withdrawal of it.

The shared-decision process

• Shared decision-making moves through choice talk (making the patient aware a real choice exists), option talk (laying out options with natural-frequency numbers, never hazard ratios), and decision talk (eliciting values and deciding together), closed by teach-back to confirm understanding. The patient's values and the agreed plan are documented and revisited as things change.

Withdrawal and end-of-life

• When PD no longer meets the patient's goals, planned withdrawal with palliative and symptom-focused care is the appropriate path. It is a shared, documented decision, made with the patient and family, and framed as a change of goals rather than an abandonment.

Five fully-built tables.

Table A — The special situations

Table B — Assisted PD

Table C — Urgent-start PD essentials

Table D — Decision types

Table E — The shared-decision steps

Visualise & Map

Numbered rules. These numbers are the cross-reference handle for the cases and flowcharts.

Clinical Reasoning

Five cases. Each stops you at a decision before it answers it.

Exhaustive. Every rule in the chapter is here.

Safety & Evidence

Panel A — Red flags

Panel B — NEVER DO

Anti-patterns clinicians fall into. Each becomes a Level 22 distractor.

The grade reflects strength of evidence, not importance.

Patient Decisions

Outcomes as natural frequencies. Figures are representative; the direction of effect is given where precise numbers are uncertain. No hazard ratios are used in patient-facing material.

Decisions where the right answer depends on the patient's values, not the evidence.

Effective-care decisions (not preference-sensitive)

• Low-volume supine exchanges for urgent-start — physiology dictates it.
• Glucose-sparing and matching dwell to transport — evidence dictates it.
• Antibiotic prophylaxis before catheter insertion — evidence dictates it.
• Treating an identified infection or mechanical complication — the clinical problem dictates it.

The conversation rehearsed as a skill. Numbers trace to Level 14.

Apply & Test

Copy-paste chart notes that map to the real decisions in this chapter.

Template 1 — Shared-decision record

• Decision: ___ ; type: effective-care / preference-sensitive.
• Options discussed: ___.
• Numbers shared (natural frequency): ___.
• Patient's stated values: ___.
• Decision reached and by whom: ___.
• Teach-back confirmed: yes/no. Revisit when: ___.

Template 2 — Goals-of-care / conservative-care note

• Prognosis and frailty summary: ___.
• Patient's goals and priorities: ___.
• Path chosen: dialysis / conservative care / planned withdrawal.
• Symptom and palliative plan: ___.
• Family involved: yes/no. Review date: ___.

Pre-rounds compression. Rules only.

Active recall. At least one card per objective.

Micro-teaching for rounds. Two scenarios, five steps each.

Metacognition anchored to this chapter's tensions. No answers provided.

1. 1. When a frail patient might do better without dialysis, what makes it hard to say so out loud — and whose discomfort is really driving the silence?
2. 2. How do you present survival numbers honestly to a patient choosing dialysis or conservative care without either steering them or overwhelming them?
3. 3. Where does your unit's convenience quietly stand in for a patient's preference, and how would you notice it happening?
4. 4. In assisted PD, how do you keep a willing family helper's burden in view so that ‘keeping her at home’ doesn't quietly cost someone else too much?
5. 5. If a decision is genuinely the patient's to make, how do you sit with a choice you might not have made yourself?

Nine items, each anchored in this chapter. At least one per objective.