Our dietitien was making her rounds last night and I overheard her conversation with an elderly patient. He is a very sweet, small man, in his 80s. He always brings a bag of candy for the nurses and is very friendly and kind to everyone. His potassium and phosphorous were both high. The dietitien was very hard on him. He made it clear that he knew what he was doing that was making his levels high but he had few pleasures at this point in his life and he was not willing to give up everything. She kept on and told him he was going to end up dying and she guessed that they would just let him have a heart attack. I think the dietitien was completely out of line. Too often patients are treated like disobedient children and talked down to. This man has been on dialysis for many years. He knows what he shouldn't eat. At this point, I think a kind reminder that his levels are high and a quick review of what not to eat, as well as a list of options would have been more appropriate. What do you all think?

Of course I was not at your facility when this occurred; however, I do agree with you that the patient is an adult, not a child and should be given the respect that all of us deserve. I have patients similar to this man, and I feel it is my responsibility as a dietitian to alert him of the dangers of high potassium and phosphorus levels always remembering that it is his responsibility to take care of himself. Maybe you misread this dietitian and mistook true concern for judgement. I think where some dietitians fall short (and I am not insinuating that your dietitian is guilty of this in any way)in outpatient dialysis care is they don't really get to know their patients personally. I think when you establish a relationship with your patients, a trust develops and the paient as well as the dietitian benefits. We all have to remember that we have an obligation to respect each other and ultimately compliance follows - most people want to please those whom they care for and respect. This elderly gentleman is right when he says he has the right to enjoy his life. The dietitian's responsibility is to ensure he has the knowledge and understanding necessary to enjoy life safely within the confines caused by his renal disease. I personally would have just reminded him that a high potassium level will effect his heart and to be very careful with the high potassium foods. I also would have taken time to find out his very favorite foods and incorporate them into his diet in safe portions. I don't believe the renal diet has to be so restrictive as to be become impossible to follow. I hope you will give your dietitian the benefit of the doubt this time and make an attempt to utilize her for her knowledge regarding your renal diet.

Our dietician shows real restraint most of the time-- I've seen her ignore potato chips on the side tables of patients. She will "go after" people about their diets only when there is a serious problem; she doesn't nit-pick over every rise in potassium or phosphorus. She gives us credit for being adults, and she was very happy to see some of the dietary restrictions eased. She didn't enjoy telling people that they could "NEVER" have bananas or tomatoes again, and patients certainly didn't enjoy hearing that the foods they loved were now forbidden. She's always willing to talk to us if we have questions. If all units had a dietician like Emily, I think patients wouldn't find it so hard to be compliant with their renal diets.

Which dietary restrictions were eazed? I eat small slices of tomatoes all the time and my labs are fine. My dietitician told me I dould eat half a banana mid week on the day before dialysis. I've never tried it as I was so afriad when I first went on dialysis that I'd die if I ate this stuff that I forgot all about her telling me that. But I saw on the net where someone else ate tomatoes in moderation and i started with the tomatoes and then one thing at a time to see what my labs could handle. I found I can eat almost anything as long as I eat it in moderation. i eat very normally now and don't feel like I'm on a renal diet at all. In my case, my dietitian scared the H___ out of me. I went through a lot of unnecessary changes. If she had just told me about the modertion rule it would of saved me and the rest of the patients a lot of agony. I didn't eat out at a restaurant for 2 years because I lacked an understanding of what I could eat and what I couldnt eat that much of..

I am glad to find out that other dietitians spend the time trying to keep patients eating as normally as possible. Not all units have dietitians who can really spend the time monitoring lab values closely and really getting to know their patients and their preferences. I think that is sad - the beauty of outpatient dialysis is getting the opportunity to really get to know your patients and become someone they can trust to talk with about their diet and lab values. I sometimes am criticized for being too lenient, but my patients are able to live more normal lives and their lab values are stil within normal limits.

Anne RD,
Could you say in what ways you are more lenient with your patients' diet? When I first came into dialysis, my dietitian scared me half to death. I actually got the impression from her that I would die if I ate a large number of things she said were on my NO list. Afer hearing reports from other patients who said they ate in moderation, thats what I began to do. I always have excellant labs and eat almost anything I want now....in moderation. What are the true no nos? I found that my dietitian was giving me a diet based on what an overeater would eat. I never overeat and have plenty of everything I could want. I don't even need renal cookbooks. I know basically what I'm supposed to limit and I just take regualr recipeies limiting whatever needs to be limited. My dietitian had told me initially that I shoudn't eat pizza, spaghetti, fast food (I don't care for junk food but have to eat it sometimes when I'm unable to cook),icecream, chocolate, raisins, nuts, dairy, tomatoes. Gosh I can't even think now, but it was a list of practically everything. I eliminated everything she said to eliminate initially and still ate well, because I'm a good cook. But now I just enjoy almost everything and I have had no problems.

Dear patient,
It sounds as though you have found the key to living healthy on dialysis! Congratulations! I wish I could help all my patients learn the lesson as well as you have. Other dietitians may call me lenient but I teach moderation. I usually find out the foods my patients enjoy the most and teach them how to eat those foods safely. i feel that the reason diets fail is because all the foods the patient loves has now been labeled a "NO NO". Those kinds of diets never work for long. Food brings comfort to many people and a sense of control and well-being, and when you take everything away, people feel hopeless and quickly lose the motivation to stay healthy and safe.
I want to take a minute to answer your question regarding the dangerous foods. I tell my patients that the one mineral they must watch closely is potassium. Potassium is not very forgiving. You could sit down one day and binge on potatoes and stop your heart. I tell my patients that they must always be aware and know their high potassium foods. I encourage them to eat only 1-2 high potassium foods a day and then to eat more from their low and medium potassium food lists. I tell them to know thie potassium levels from monthly labs and try to always keep their levels less than 5.5.
I hope this answered your questions.

I am a RN in a hemodialysis unit in a prison--unfortunately there are not any dieticians
available to help our patients. Many of them are brand new dialysis patients and need lots of education--ESPECIALLY on their renal diets. I am wondering if anyone has any good information that we could obtain--any teaching materials, handouts, anything would be better than what we have--nothing!!

Ryan,
There is some excellent info on "ikidney.com" about a renal diet. The "nutritional compliance tips" can be printed from your computer, and I copy them & use as patient handouts. I really like the list of OK foods. There are also some recipes available. You may want to contact Amgen & request the "Living Well" cookbook. It has sample recipes & tips. I print it from a 3.5 disk. Hope this helps!

I think the reason that dieticians come off as "strict" when you first start dialysis is that they are concerned about the high levels of toxins in your bloodstream, and don't want you dumping more of them in before the dialysis can start to work. Once you get "cleaned up" through dialysis, moderation works. Also, this is the first time adults have had other adults telling them what to eat! That's somewhat unsettling in itself. If people feel they have choices, they're more likely to do tradeoffs than if they are given a sheet of paper and told not to eat any of the foods on the list. Whoever started that "No-no" list was well-meaning but misinformed. Your body is set up to utilize certain minerals and suddenly omitting them could cause problems in other body systems. Sometimes too little of a mineral can be harmful, too.