Second-Chance Placement of Hemodialysis Patients After Involuntary Discharge for Disruptive Behavior

A small subset of hemodialysis patients exhibits persistently disruptive behavior. When all reasonable attempts to stop such behavior have been exhausted, they may undergo involuntary discharge from their dialysis unit. Such patients typically present repeatedly to the emergency department for urgent inpatient dialysis. We describe a novel approach to achieve a successful "second-chance" placement at a new outpatient dialysis unit. The patients were required to dialyze in the inpatient unit for a minimum of 3 months, during which their compliance and behavior were observed closely. In parallel, an experienced social worker in the emergency department applied a structured protocol. The approach included debriefing about the incident leading to the discharge, coaching about building a trusting relationship with the nephrologist and dialysis staff, education about constructive handling of grievances, and arranging a face-to-face office interview with the medical director to determine their potential acceptance. Finally, the emergency department social worker conducted a formal handoff with the social worker at the accepting facility. During a 4-year period, we accrued 12 patients with an involuntary discharge. Following this protocol, 7 of them have been successfully placed at a new outpatient dialysis unit for 77 to 650 days without recurrence of disruptive behavior.