Death During Dialysis
Brief Past Medical History
The patient was a middle-aged African-American woman with a history of polycystic kidney disease requiring dialysis.
The patient had multiple surgical dialysis access sites created over time (left arm shunt, left leg shunt, right arm arteriovenous fistula).
Recently, she had two episodes of bleeding from the right arm arteriovenous fistula during dialysis.
For the second episode, she received transfusions.
No therapeutic or surgical treatments were made to the arteriovenous fistula.
Day of Death
The patient had a third episode of bleeding from her right arm arteriovenous fistula during dialysis resulting in her death.
The history is obtained from the family.
1. How do you interpret the history?
2. What is polycystic kidney disease?
3. What is the difference between a dialysis shunt and an arteriovenous fistula?
4. Why might patients need multiple dialysis access sites? Is this common?
5. Given that the patient was using the right arm arteriovenous fistula during dialysis, what can you presume about the other two access sites (i.e., do you think they were functional or not)?
6. Why might a arteriovenous fistula bleed?
7. How do you interpret the patient’s care plan?
8. The amount of bleeding is not specified. How much bleeding do you think there was during the second episode? What’s your evidence?
9. Is there a scenario where the overall care plan was appropriate?
10. Thinking of the patient as your own, what might you have done differently?