Factors Affecting Quality of Life In Persons on Hemodialysis

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Factors Affecting Quality of Life In Persons on Hemodialysis

  1. 1. Factors Affecting Quality of Life In Persons on Hemodialysis Continuing Nursing Education Daria L. Kring Patricia B. Crane ore than 470,000 people live M The purpose of this cross-sectional, correlational study was to describe the quality of life with end stage renal disease (QOL) in persons with end stage renal disease and explore factors that may affect QOL. (ESRD), the final stage of Biological function, symptoms, function, general health perception, and characteristics of chronic kidney disease, and the individual and environment explained 61% of the variability in overall QOL. Only each year, more than 100,000 addi- anxiety, depression, and general health perception significantly contributed to QOL. tional people are diagnosed with QOL may be better predicted from psychological factors than physiological factors. ESRD (U.S. Renal Data System [USRDS], 2008). In 2006, Medicare Goal costs for ESRD topped $23 billion To provide an overview of factors that affect the quality of life in persons on hemodial- (6.4% of the entire Medicare budget) ysis. (USRDS, 2008). Incidence of ESRD has dramatically increased over the Objectives past decade, increasing from 261.3 1. Describe the quality of life in persons with end stage renal disease as found in this per million population in 1994 to correlational, cross-sectional study. 348.6 per million in 2004 (Centers for 2. List factors that have been determined to affect quality of life. Disease Control and Prevention, 3. Explain how those factors may affect quality of life in persons on end stage renal 2007), placing a significant financial disease. burden on the healthcare system. Given these figures, it is imperative that persons with ESRD receive not only cost-effective care, but also care 1999), and in many dialysis centers, ceptual clarity regarding the meaning that contributes to an acceptable qual- “life at any cost” is the unspoken rule of QOL. The more specific term ity of life (QOL). However, the QOL (Russ, Shim, & Kaufman, 2007). The “health-related quality of life” is often for persons with ESRD has been lower QOL associated with ESRD interchanged with the more holistic shown to be lower than that of the may be related to physical complica- term “quality of life.” Health-related general public (Cleary & Drennan, tions common in ESRD, such as QOL is often defined and measured 2005; DeOreo, 1997; Ferrans & fatigue, joint pain, and anorexia as “physical functioning,” a narrower Powers, 1993; Frank, Auslander, & (Phillips, Davies, & White, 2001). view than general QOL. Thus, very Weissgarten, 2003; Merkus et al., More concerning is that persons with little research has been conducted on ESRD have a lower QOL than per- the broader concept of QOL in per- Daria L. Kring, PhD, RN-BC, is the Director of sons with other chronic illnesses sons with ESRD and factors that con- Nursing Research, Forsyth Medical Center, (Loos, Briancon, Frimat, Hanesse, & tribute to it. This broad concept is Winston-Salem, NC, and a member of ANNA’s Kessler, 2003), and that QOL is cor- best defined as a person’s sense of Cardinal Chapter. related with hospitalization and death well-being that stems from satisfaction Patricia B. Crane, PhD, RN, FAHA, is an in persons with ESRD (DeOreo, or dissatisfaction with the areas of life Associate Professor, the University of North Carolina 1997). However, studies using QOL that are important to him or her at Greensboro, Greensboro, NC. as an outcome are difficult to interpret (Ferrans, Zerwic, Wilbur, & Larson, Acknowledgments: The authors wish to thank to and synthesize due to a lack of con- 2005). Nita Gaines, RN, for her invaluable assistance with data collection. Authors’ Note: This study was supported by a grant This offering for 1.4 contact hours is being provided by the American Nephrology Nurses’ made available by the American Nephrology Nurses’ Association (ANNA). Association. The views expressed herein are those of ANNA is accredited as a provider of continuing nursing education (CNE) by the American the authors, and no official endorsement by the Nurses Credentialing Center’s Commission on Accreditation. American Nephrology Nurses’ Association is intend- ed or should be inferred. ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP 00910. Disclosure Statement: The authors reported no actual or potential conflict of interest in relation to This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu- this continuing nursing education article. ing nursing education requirements for certification and recertification. NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1 15
  2. 2. Factors Affecting Quality of Life in Persons on Hemodialysis Figure 1 Revised Wilson and Cleary Model of Quality of Life Characteristics of the Individual General Overall Biological Functional Symptoms Health Quality of Function Status Perceptions Life Characteristics of the Environment Note: Used with permission from Wiley Blackwell Publishing. Purposes • Do biological function (serum serum hemoglobin), symptoms albumin and serum hemoglobin), (dialysis symptoms, anxiety, The purposes of this study were to symptoms (dialysis symptoms, depression, and fatigue), function- describe the QOL in persons with anxiety, depression, and fatigue), al status, and general health per- ESRD and examine factors which functional status, and general ception explain overall QOL in influence QOL. health perception explain overall persons with ESRD? QOL in persons with ESRD? Conceptual Framework • Do biological function (serum Design albumin and serum hemoglobin), A revised version of Wilson and symptoms (dialysis symptoms, This non-experimental research Cleary’s (1995) model for QOL anxiety, depression, and fatigue), study employed a cross-sectional, cor- (Ferrans et al., 2005) was used to functional status, general health relational design to determine factors guide this study (see Figure 1). perception, characteristics of the affecting QOL in persons on hemo- According to this model, there are individual (age, gender, and race), dialysis. The data collection took four main determinants of overall and characteristics of the environ- place in a free-standing, outpatient QOL: biological function, symptoms, ment (marital status, socioeco- dialysis clinic located in the southeast- functional status, and general health nomic status, and time on ern United States. Convenience sam- perceptions. Characteristics of the hemodialysis) explain overall pling was used to obtain participants individual and environment influence QOL in persons with ESRD? from the outpatient dialysis clinic. all determinants, as well as QOL. • When controlling for characteris- Inclusion criteria consisted of actively undergoing incenter hemodialysis, on tics of the individual (age, gender, hemodialysis for at least three months, Research Questions and race) and characteristics of at least 18 years of age or older, and the environment (marital status, The research questions were: able to speak and understand the socioeconomic status, and time • What is the QOL in persons with English language. Exclusion criteria on hemodialysis), do biological ESRD? consisted of a diagnosis of dementia function (serum albumin and 16 NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1
  3. 3. or other condition that may impair used to collect information not cap- 8 for each subscale (Bjelland, Dahl, the ability to answer questions and tured on the other instruments. It Haug, & Neckelmann, 2002). Con- cognitive or medical changes occur- included characteristics of the individ- current and construct validity have ring during the hemodialysis treat- ual (age, gender, and race), character- been reported in several studies ment that prevented the person from istics of the environment (time on (Bjelland et al., 2002; Zigmond & answering questions. hemodialysis, marital status, and Snaith, 1983). Cronbach’s alpha for this An a priori power analysis was socioeconomic status), and most study for the total instrument was conducted using nQuery Advisor® recent serum albumin and hemoglo- 0.779, for the anxiety subscale was software to determine the needed bin levels. 0.805, and for the depression subscale sample size to answer the research was 0.622. questions. For multiple linear regres- Dialysis Symptom Index sion analysis, with a significance level The Dialysis Symptom Index Fatigue Visual Analog Scale of 0.05, 80% power, a total of 15 pre- (DSI) is a comprehensive instrument A visual analog scale (VAS) was dictor variables, and an estimated that measures 30 common physical used to measure fatigue in this study. moderate effect size (R2 = 0.25), 70 and emotional symptoms experi- The left VAS anchor indicated “no subjects were needed. A conservative enced by persons on hemodialysis fatigue,” and the right anchor indicat- R2 was estimated from a study using and the severity/frequency of those ed “severe fatigue.” Measurements the Quality of Life Index – Dialysis symptoms (Weisbord et al., 2004). were made from the “no fatigue” version with persons on hemodialy- Each participant was asked if a symp- anchor to the participant’s mark. sis, in which the R2 was reported as tom was experienced during the past Thus, the higher the number, the 0.28 ( Jablonski, 2007). week. If yes, the participant was asked worse the fatigue. It is a quick, simple to what degree the symptom was tool to complete and has correlated bothersome on a 5-point scale, with 1 well with longer instruments, includ- Protection of Human Subjects = not at all, and 5 = very much. The ing Belza’s Multi-Dimensional Assess- The study was approved by the responses on the severity dimension ment of Fatigue Scale (r = 0.80), the Institutional Review Board (IRB) of were added together for a possible vitality subscale from the SF-36 (r = The University of North Carolina at total symptom severity score of 0 to 0.71), and the Brief Fatigue Inventory Greensboro. In addition, permission 150. The tool’s development, includ- (r = 0.76) (Wolfe, 2004). to conduct the study at the dialysis ing validity assurance, is discussed clinic was obtained from the corpora- elsewhere in the literature (Weisbord Inventory of Functional tion’s department of clinical studies. et al., 2004). Test-retest reliability with Status – Dialysis All participants were approached persons on hemodialysis 4 to 7 days The Inventory of Functional Status by a nurse employee to briefly apart was high (M = 0.80, SD = 0.09). – Dialysis (IFS-D) was developed and explain the study and ascertain inter- Cronbach’s alpha for this study was tested specifically for persons on dial- est. All those indicating interest were 0.87. ysis (Thomas-Hawkins, 2005). The fully informed regarding the purpose participant must rate each activity of the study and expectations of par- Hospital Anxiety and according to the degree of participa- ticipation. A written consent form Depression Scale tion in a typical week in the past was reviewed and signed by each The Hospital Anxiety and Depress- month on a 4-point scale: 1 = did not participant prior to collecting data, ion Scale (HADS) was developed as a do, 2 = did with a lot of help, 3 = did and each participant received a copy. short tool to identify patients at risk for with some help, and 4 = did by Confidentiality was maintained on all two common psychological disorders – myself. Points are given for each data collection forms by using codes anxiety and depression (Zigmond & activity and averaged to determine an to identify participants instead of Snaith, 1983). The HADS has 14 items overall functional status score, rang- names or any other personal identi- – 7 related to anxiety and 7 related to ing from 1.00 to 4.00. A higher score fiers. A master list of participant depression. Each item is a statement to indicates a higher level of functioning. names was kept separate from the which respondents choose the degree Validity of the tool was documented data collection forms. All data collec- to which the statement is true on a 4- by the tool’s author (Thomas- tion forms are kept in a locked file in point Likert-type scale, from 0 to 3, Hawkins, 2005). Alpha reliability for the investigator’s office separate from with 0 representing no symptoms, and the total scale score was 0.88, and the master list. 3 representing the clear presence of subscale reliabilities ranged from 0.75 symptoms related to anxiety or depres- to 0.85 (Thomas-Hawkins, 2005). For sion. The two subscales (HADS-A and this study, the alpha reliability was Instruments HADS-D) are summed separately and 0.860. Dialysis Demographic Form may also be added together for a total score. The cut-off score for determining Palliative Performance Scale The Dialysis Demographic Form, the presence of anxiety or depression is The Palliative Performance Scale an investigator-designed form, was NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1 17
  4. 4. Factors Affecting Quality of Life in Persons on Hemodialysis (PPS) (Anderson, Downing, Hill, degree to which individuals are satis- Table 1 Casorso, & Lerch, 1996), a modifica- fied with a certain aspect of their life Demographic Statistics (N = 73) tion of the Karnofsky Performance and is measured on a 6-point Likert- Scale (KPS), measures the decline in type scale, with 1 = very dissatisfied, Frequency function seen in terminal patients as and 6 = very satisfied. The second Variable (%) they approach death. The index item asks the level of importance of Gender ranges from 100% (normal, no evi- that aspect of their life, and is also Female 40 (55%) dence of disease) to 0% (deceased). measured on a 6-point Likert-type The scale progresses in 10% incre- scale, with 1 = very unimportant, and Male 33 (45%) ments within these two anchors to 6 = very important. The satisfaction Race/Ethnicity describe overall level of function. scores are recorded and weighted African American 56 (76%) Persons are classified against 5 cate- according to the importance scores to gories: ambulation, activity/evidence determine an overall QOL score. White 13 (18%) of disease, self-care, intake, and level Possible range for the final score is 0 Hispanic 2 (3%) of consciousness according to descrip- to 30, with higher scores indicating a tors for each percentage from 0 to higher overall QOL. Validity for the Other 2 (4%) 100. Because the PPS was designed to QLI-D has been documented by the Marital Status predict death, evidence of construct authors (Ferrans, 1990, 2006; Ferrans Married 24 (33%) validity has been supported by its & Powers, 1985, 1992, 1993). Across prognostic capacity (Anderson et al., 48 studies involving persons of vary- Never married 21 (29%) 1996; Harrold et al., 2005; Lau, ing diagnoses, Cronbach’s alpha has Divorced/separated 15 (20%) Downing, Lesperance, Shaw, & ranged from 0.73 to 0.99, and 0.88 to Widowed 12 (18%) Kuziemsky, 2006; Virik and Glare, 0.93 for persons on dialysis (Ferrans, 2002). 2006). Cronbach’s alpha in this study Annual Family Income was 0.937. Above poverty 41 (56%) General Health Perceptions Below poverty 22 (30%) General health perception is often Procedures Do not know 6 (8%) measured with one global question that allows the individual to synthe- A letter explaining the study was Prefer not to answer 3 (4%) size all objective and subjective expe- provided to each eligible, interested riences regarding his or her personal person. All participants receiving a Missing data 1 (2%) health (Wilson & Cleary, 1995). This recruitment letter were approached Likelihood of Transplant factor was measured by one item, as by the investigator to answer ques- Not likely 37 (51%) recommended by Ferrans et al. tions and obtain consent. Participants (2005): “How would you rate your completed the study instruments dur- Probably not likely 5 (7%) health on a scale from 1 to 10, with 1 ing a routine dialysis session. Data Somewhat likely 8 (11%) = poor and 10 = excellent?” collection did not occur until the per- Very likely 16 (22%) son had been on dialysis for at least Quality of Life Index – 60 minutes. I do not know 7 (9%) Dialysis Participants received a thank you The Quality of Life Index – letter from the primary investigator Dialysis Version III (QLI-D) is a sub- and a $10 bill immediately following alpha = 0.05, but the overall model jective, self-report measure composed completion of all instruments as a was set at alpha = 0.01. This higher of 34 pairs of questions (Ferrans & token of appreciation for their time and significance level for the overall Powers, 1985). Thirty-two items make willingness to share their experiences. model was chosen to prevent a Type I up the core version of the QLI and error due to multiple analyses. assess health care, physical health and Data Analyses functioning, occupation, education, leisure, the future, peace of mind, per- All data were entered into SPSS Results sonal faith, life goals, personal version 15.0. Descriptive statistics The sample consisted of 73 patients appearance, self-acceptance, general were calculated for each variable. on hemodialysis. Most participants happiness, and general satisfaction. Various multiple regression models were female (55%), African American Two additional questions are included were conducted to answer specific (76%), and not married (67%). Over in the QLI-D that assess changes due research questions. Assumptions for half reported household incomes to kidney failure and the possibility of multiple regression were verified above the federal poverty level (56%) a kidney transplant. For each pair of prior to the analyses. Statistical signif- and felt they were not likely to receive questions, the first item asks the icance for each variable was set at a kidney transplant (58%). Ages 18 NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1
  5. 5. Table 2 Health-Related Variables (N = 73) Variable Mean SD Range Possible Range Serum Albumin 3.90 g/dL 0.40 2.1 to 4.6 3.5 to 4.5 (normal range) Serum Hemoglobin 12.58 g/dL 1.67 9.4 to 17.8 12 to 16 (normal range) Dialysis Symptoms 41.85 23.30 5 to 110 0 to 150 Anxiety 6.52 4.27 0 to 18 0 to 21 Depression 5.36 3.16 0 to 15 0 to 21 Fatigue 43.27 27.36 0 to 100 0 to 100 Inventory of Functional Status (IFS) 3.00 0.65 1.47 to 4.00 1 to 4 Functional Status (PPS) 75.89 12.42 50 to 100 0 to 100 General Health Perception 5.67 1.83 1 to 10 1 to 10 Quality of Life – Overall 21.14 4.87 7.45 to 30.00 0 to 30 Health and functioning 18.92 5.48 4.00 to 30.00 0 to 30 Socioeconomic 21.57 5.81 5.50 to 30.00 0 to 30 Psychological/spiritual 22.96 5.73 8.50 to 30.00 0 to 30 Family 24.71 5.40 8.20 to 30.00 0 to 30 ranged from 20 to 89 years old, with a variables were entered together as health-related variables to the model mean age of 56 years (SD = 15.8). one block. This model significantly improved the explanation of variance Time on hemodialysis ranged from 3 explained 59% (R2 = 0.589; R2adj = in overall QOL after the characteris- months to 301 months (25 years) with 0.530) of the variance in overall QOL tics of the individual and the environ- a mean of 56 months (SD = 58.3). (F = 9.887 [9, 62], p < 0.001). The sig- ment were already taken into account. Demographic data are displayed in nificant variables contributing to the Characteristics of the individual and Table 1. The health-related variables model were serum albumin (square characteristics of the environment are summarized in Table 2. root), anxiety, depression, and gener- were entered into the multiple regres- al health perception. sion model as the first block, and the other 9 health-related variables were Research Question #1: Overall entered together as the second block. Quality of Life Research Question #3: Characteristics of the individual and All Variables The overall QOL was 21.14 (SD = environment did not significantly con- 4.87) out of a possible score of 30. A This question included characteris- tribute to overall QOL (F = 1.310 [6, higher score on the QLI-D indicates a tics of the individual and environ- 64], p = 0.266). However, after con- higher QOL; thus, the average ment, in addition to the health-related trolling for individual and environ- reported score is higher than the variables. All 15 independent vari- mental characteristics, model two sig- midrange value of 15. Simple correla- ables were entered together as one nificantly explained 61% (R2 = 0.608, tions were conducted to inspect the block. This model significantly R2adj = 0.501) of the variance in over- relationships between all continuous explained 61% (R2 = 0.608; R2adj = all QOL (F = 7.781 [9, 55], p < 0.001). variables in the study (see Table 3). 0.501) of the variance in overall QOL Again, anxiety, depression, and gener- Six variables correlated significantly (F = 5.693 [15, 55], p < 0.001). The al health perception were the only sig- (p < 0.05) with QOL: dialysis symp- significant variables contributing to nificant contributing variables. toms, anxiety, depression, fatigue, the model were anxiety, depression, palliative performance scale, and gen- and general health perception (see Interpretation of Results eral health perception. These correla- Table 4). tions were low to moderate in Quality of Life strength (Munro, 2005). The mean QOL for this sample Research Question #4: Controlling For Characteristics Of Individual was 21.14 (SD = 4.87). This finding Research Question #2: And Environment was similar to other studies reporting Health-Related Variables Quality of Life Index-Dialysis (QLI- Sequential regression was em- D) scores of persons with ESRD All 9 health-related independent ployed to determine if the addition of (Bihl, Ferrans, & Powers, 1988; NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1 19
  6. 6. Factors Affecting Quality of Life in Persons on Hemodialysis Table 3 Intercorrelations of Continuous Variables (N = 73) Variable 1 2 3 4 5 6 7 8 9 10 11 12 QLI-D – 099 -0.080 0.480** -0.502** -0.576** -0.282* 0.172 256** 0.583** 0.180 0.165 Albumin – 313** -0.104 -0.259* -0.294* -0.049 0.343** 0.283* 0.198 -0.197 0.327** Hemoglobin – 0.066 -0.092 0.152 0.107 -0.283* -0.303** -0.097 0.043 0.141 DSI – 0.403** 0.390** 0.394** -0.067 -0.241* -0.465** -0.159 0.003 Anxiety – 0.352** 0.085 -0.019 -0.076 -0.244* -0.400** -0.208 Depression – 0.325** -0.350** -0.281* -0.394** -0.001 -0.352** Fatigue – -0.159 -0.258* -0.280* -0.023 -0.165 IFS-D – 0.695** 0.296* -0.524** 0.213 PPS – 0.277* -0.407** 0.251* GHP – -.024 0.135 Age – -0.119 Time on Dialysis – Variables QLI-D = Quality of Life Index – Dialysis PPS = Palliative Performance Scale DSI = Dialysis Symptom Index GHP = General Health Perception IFS = Inventory of Functional Status – Dialysis *P < 0.05 **P < 0.001 Table 4 Multiple Regression Summary for All Variables on Overall Quality of Life (N = 73) Standardized Regression Coefficient t P Albumin (square root) 0.151 1.333 0.188 Hemoglobin 0.096 0.890 0.378 Dialysis Symptom Index 0.014 0.119 0.906 HADS – Anxiety Subscale -0.286 -2.439 0.018* HADS – Depression Subscale -0.413 -3.645 0.001* Fatigue VAS -0.020 -0.198 0.844 Inventory of Functional Status – Dialysis -0.117 -0.797 0.429 Palliative Performance Scale (PPS) 0.230 1.671 0.100 Gernal Health Perception 0.363 3.303 0.002* Age 0.046 0.361 0.719 Female Gender 0.064 0.604 0.549 African American Race 0.043 0.455 0.651 Time on Hemodialysis (square root) -0105 -1.027 0.309 Married Status 0.074 0.769 0.445 Income Above Poverty -0.002 -0.018 0.986 R2 = 0.608; R2adj = 0.501; F = 5.693 P < 0.001 *P < 0.05 20 NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1
  7. 7. Ferrans & Powers, 1993; Greene, 0.049), and when an outlier case was total DSI score for this study, which 2005; Jablonski, 2007; Laws, Tapsell, removed from the model, it was not takes into account the severity of & Kelly, 2000). These studies report- significant (p = 0.055). When examin- symptoms, was 41.85 (SD = 23.30). ed mean QOL scores between 20.70 ing bivariate correlations, albumin The median value was 38. Although to 22.67. Reported mean QOL scores did not significantly correlate with Weisbord and colleagues (2005) did using the QLI for other populations overall QOL (r = 0.099). These find- not report a mean, the median was range from 17.4 (SD = 5.4) for persons ings are similar to an earlier study that 25. Therefore, participants in this living with chronic pain (Gerstle, All, did not find a significant correlation study reported a greater number and & Wallace, 2001) to 21.01 (SD = 4.27) between albumin and QOL (Patel, higher severity of symptoms than pre- for persons with spinal cord injuries Shah, Peterson, & Kimmel, 2002). viously reported. Although the DSI (May & Warren, 2002). Persons with Hemoglobin also did not con- correlated significantly with overall ESRD in this study reported a QOL tribute to any of the regression mod- QOL (r = 0.480, p < 0.001), it did not better than these populations. A sur- els and did not correlate with QOL. contribute significantly to overall prising finding was that the mean Other studies report similar results QOL in the total model. These results score in this study was only slightly (Frank et al., 2003; Kalantar-Zadeh, are intriguing given the heavy symp- lower than a group of healthy persons Kopple, Block, & Humphreys, 2001; tom burden reported by participants. (M = 21.9) using the general popula- Patel et al., 2002). Although 43% of Jablonski (2007) found that symptom tion version of the QLI (Ferrans, participants in this study had hemo- scores, level of relief, and satisfaction Cohen, & Smith, 1992). globin levels less than normal, the with relief accounted for 28% of the The study findings suggest that reason they did not significantly con- variance in QOL for persons with persons with ESRD experience a rel- tribute to QOL may be adaptation to ESRD. Because Jablonski’s model atively comparable QOL. Given their persistently low levels. Thus, persons focused solely on symptoms, it may symptom burden and intensive dialy- with ESRD may not experience the be that once a more complex model sis regimen, such findings may seem symptoms or the intensity of the is created, symptoms no longer factor curious. However, it has been sug- symptoms that other persons with in as a significant determinant of gested that people adjust their life low hemoglobin levels might report. overall QOL. aspirations according to changes in In fact, in the present study, hemoglo- Fatigue was also prevalent in this life circumstances to maintain subjec- bin did not significantly correlate with study, with over 91% of participants tive well-being (Ferrans & Powers, fatigue (r = 0.107, p = 0.368), a com- reporting some level of fatigue. Other 1993). The results of this study indi- mon symptom of anemia. Further, studies have reported fatigue preva- rectly support such an adaptation. supplemental erythropoietin injec- lence between 77% and 90% (Curtin, The comparatively normal QOL tions often assist patients on dialysis Bultman, Thomas-Hawkins, Walters, score demonstrated in this study is a in maintaining adequate hemoglobin & Schatell, 2002; Frank et al., 2003; particularly encouraging finding be- levels. Thus, persons on hemodialysis Jablonski, 2007; Merkus et al., 1999; cause it suggests that the complex may be able to sustain normal hemo- Weisbord et al., 2003). Participants in medical care required for this popula- globin levels or adapt to low levels, this study reported a mean fatigue tion provides a manageable QOL. In rendering it an insignificant factor in level of 43.27 (SD = 27.36) using a 100 addition, it lends support to the large perceived QOL. As measures of bio- mm visual analog scale (VAS). This amounts of federal funding dedicated logical function, the results of this result is similar to another study with to the care of persons with ESRD. study did not provide convincing sup- African-American women on dialysis port that either albumin or hemoglo- using a fatigue VAS in which the Health-Related Factors bin contributes to overall QOL in reported mean was 44.6 (SD = 33.1) The 9 health-related factors in the persons with ESRD. (Williams, Crane, & Kring, 2007). model significantly explained 59% of Fatigue exhibited a low, negative cor- the variance in overall QOL. This Symptoms relation with QOL but did not con- finding lends support to the important Dialysis symptoms, fatigue, anxi- tribute to the overall model. There- role that health-related factors play in ety, and depression were the symp- fore, fatigue, as well as other common overall QOL. However, only albumin, tom factors selected for this study. dialysis symptoms, does not seem to anxiety, depression, and general health Dialysis symptoms were prevalent. be a significant determinant of QOL in perception were significant variables. Participants in this study reported a multi-factorial model. It may be that from 2 to 29 symptoms, with a mean persons with ESRD are able to adapt Biological Function of 12.95 (SD = 5.93) symptoms. The to their chronic symptom burden with- Albumin significantly contributed mean number of symptoms in this out it interfering significantly with their to QOL when the independent vari- study was more than other studies day-to-day QOL. Indeed, the symp- ables were limited to health-related that have reported: 5.67 ( Jablonski, toms are not acute in nature, but might factors. However, the significance 2007), 7.7 (Frank et al., 2003), and 9.8 be described by persons on dialysis as level for albumin was borderline (p = (Weisbord et al., 2005). The mean dull and nagging. In addition, many NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1 21
  8. 8. Factors Affecting Quality of Life in Persons on Hemodialysis symptoms might be adequately man- 2000). This difference may be due to a debilitation perceived their health sta- aged with medication or other inter- scale modification that included a “not tus as good to excellent. Because ventions rendering them less of a fac- applicable” choice. This modification ESRD is a chronic condition, many tor in overall QOL. was made so that a person who can persons living with the disease may Anxiety was also prevalent in the physically engage in an activity (such readjust their definition of health. study sample. Using a cut point of 8 on as preparing meals) but chooses not to This “response shift” has been noted the anxiety subscale of the HADS, could provide a more accurate in persons as a way to cope with the 41% of participants were anxious. This response. The modification resulted in effects of illness (Ferrans, 2005). The finding is much higher than a general higher scale totals but did not yield sig- medical regimen associated with population sample, who reported anx- nificant results. In addition, it did not renal failure, including diet, medica- iety prevalence at 13% (Cohen, Magai, correlate with overall QOL nor con- tions, and dialysis, may become the Yaffee, & Walcott-Brown, 2006), and tribute significantly to any of the new health baseline. Therefore, as slightly higher than other studies, regression models. long as no other illness processes are which have reported anxiety among The mean PPS score was 75.89 (SD occurring, health is maintained persons with ESRD at 36% (Williams = 13.42). Other studies using the earli- according to the person’s adjusted et al., 2007) and 38% (Murtagh, er KPS have had similar results. One internal standards. Addington-Hall, & Higginson, 2007). study reported a mean KPS of 74.5 Unlike other symptoms examined (SD = 16.6) (Patel et al., 2002), and Characteristics of the in the study, anxiety was an important another reported mean values Individual health-related variable. It correlated between 63.80 to 80.70 (Laws et al., Three characteristics of the indi- negatively with QOL and significantly 2000). These similarities lend support vidual were selected for inclusion in contributed to every regression model. to the use of the PPS in the renal pop- the study: age, gender, and race/eth- Interestingly, none of the ESRD QOL ulation. For this study, the PPS showed nicity. None of these variables were studies reviewed included anxiety as a low, positive correlation with overall significant in any of the regression an independent variable. Therefore, QOL. However, it was not a signifi- models. According to the most cur- this finding may provide important cant contributor to any of the regres- rent USRDS (2006) report at the time insight into a vital determinant of sion models. This finding may also be of this study, the mean age of all per- QOL for persons with ESRD. related to adaptation by persons with sons with ESRD in the United States Depression was another important ESRD to their chronic condition and is 57.9 years, over half of the persons health-related variable in this study. the relative value of functional status to with ESRD are male (56%), 61% are Using a cut-point of 8 on the HADS, overall QOL. White, and only 32% are African 27% of participants were depressed. American. Thus, participants in this This finding mirrored other studies General Health Perception study were slightly younger and con- that reported a 28% prevalence rate The general health perception sisted of both more females and sig- (Drayer et al., 2006; Murtagh et al., mean score was 5.67 (SD = 1.83). nificantly more African Americans 2007; Weisbord et al., 2005). The General health perception correlated than the U.S. ESRD population. mean of 5.36 (SD = 3.16) was identical higher, with overall QOL than any of to another study using the HADS in the other independent variables and Characteristics of the persons with ESRD in which the was a significant contributor to all the Environment mean was 5.4 (SD = 3.52) (Williams et regression models. These results are Three characteristics of the envi- al., 2007). Similar to anxiety, depres- similar to another hemodialysis study ronment were selected for inclusion sion exhibited a negative correlation that also measured general health per- in the study: marital status, socioeco- with QOL and significantly con- ception with a single 10-point Likert- nomic status, and time on dialysis. tributed to every regression model. type scale in which the mean general Like characteristics of the individual, health perception was 6.5 (SD = 1.94) none of these variables were signifi- Functional Status and correlation with QOL (as meas- cant in any of the regression models. Function was measured with two ured by the QLI-D) was also similar instruments, the Inventory of Functio- (Bihl et al., 1988). The Revised Wilson and nal Status-Dialysis (IFS-D) and the The significance of general health Cleary Model of Quality Palliative Performance Scale (PPS). perception is an important finding. Of Life The participants in this study had a When trying to evaluate QOL, results The conceptual framework guid- mean IFS-D score of 3.00 (SD = 0.65). from the current study indicate that it ing this study was the revised Wilson This finding is quite different from a may be important to understand the and Cleary model of QOL (Ferrans et study by the instrument’s developer in burden of disease from the person’s al., 2005). Although the main antece- which the mean IFS-D for 104 patients point of view. During data collection, dents to overall QOL in this model on dialysis was reported to be between this researcher found it interesting are health factors, the model also 1.29 and 1.37 (Thomas-Hawkins, that some persons with considerable includes characteristics of the individ- ual and characteristics of the environ- 22 NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1
  9. 9. ment, which make it a holistic schema for both anxiety and depression due clusion corroborates a meta-analysis for understanding QOL. The frame- to nondescript symptoms, such as of 12 studies that found that mental work provided guidance in selecting feeling tired and sleeping more, health had a much greater impact on variables that may impact overall which may be accepted as normal QOL than physical function (Smith, QOL. Together, the variables explain- consequences of dialysis. In addition, Avis, & Assmann, 1999). The meta- ed 61% of the variance in QOL for patients may be embarrassed to dis- analysis included five different chron- persons with ESRD. This is an impor- cuss these feelings with their health- ic diseases, although ESRD was not tant finding because other ESRD care providers or consider their feel- represented. These studies coupled QOL studies have only explained 3% ings trivial in relation to other physi- with the results of the present study (Sesso, Rodrigues-Neto, & Ferraz, cal problems. However, because provide support for a holistic ap- 2003) to 28% ( Jablonski, 2007) of the emotional health appears to have a proach to QOL. variance in QOL. These studies did large influence on QOL in this study, Nurses have the potential to direct- not use as many variables as the pres- a comfortable rapport should be ly influence QOL through interven- ent study, and thus, may have been developed with each person to allow tions that may help patients rebalance limited in their explanatory power. expression of such feelings. Pharma- their lives. Innovative therapies that cological and non-pharmacological use holistic approaches to healing may interventions should be explored in promote healthier adaptations to Implications for Nephrology Nurses collaboration with the healthcare team ESRD. Examples of possible interven- QOL is a complex construct with until psychological needs are met. tions include meditation, energy work, numerous antecedents. It should be Fatigue is highly prevalent in the music therapy, support groups, and an important outcome measure for all dialysis population. Besides having a spiritual counseling. Exploration of persons with ESRD to ensure that physical impact, this debilitating these complementary approaches to healthcare resources dedicated to this symptom can also take an emotional care may reveal beneficial interven- population are providing a sense of toll. Assessing individuals for their tions that might improve overall QOL. well-being and satisfaction with life. level of fatigue should be conducted Determination of QOL is an Ascertaining QOL requires direct on a frequent basis. When fatigue important outcome measure for per- input from the patient, and thus, can- cannot be adequately controlled, pro- sons on dialysis. Understanding fac- not be assessed independently by a viding emotional support through tors that influence well-being will clinician. active listening may provide some allow nurses to focus on specific inter- Symptom burden can be extreme empathetic relief and build a trusting ventions for enhancing QOL. When in persons on dialysis. Individuals nurse-patient relationship. examined from a holistic framework, should be assessed for symptoms Determining general health per- such as the revised Wilson and Cleary every dialysis session and a plan of ceptions may be an important way for model, targeting psychological factors care communicated to all members of nurses to gain insight into patients’ may be one of the most beneficial the healthcare team. Those on dialy- health experiences. According to this avenues to explore. sis need to be encouraged to discuss study, a person’s perception of gener- both physical and emotional symp- al health has significant bearing on References toms and not accept them as a routine overall QOL, and therefore, it Anderson, F., Downing, G.M., Hill, J., part of dialysis. A team focus toward becomes a unique indicator of well- Casorso, L., & Lerch, N. (1996). symptom management may offer a being. Low perceptions of general Palliative Performance Scale (PPS): more comprehensive approach for health may warrant further explo- A new tool. Journal of Palliative Care, alleviating physical symptoms and ration to determine underlying caus- 12(1), 5-11. Bihl, M.A., Ferrans, C.E., & Powers, M.J. provide emotional support for deal- es. High perceptions of general health (1988). Comparing stressors and ing with the psychological burden may provide additional validation quality of life of dialysis patients. associated with ESRD. that overall QOL is acceptable. ANNA Journal, 15, 27-37. Anxiety and depression are two Of all the variables included in this Bjelland, I., Dahl, A.A., Haug, T.T., & symptoms that require special vigi- study, three were particularly impor- Neckelmann, D. (2002). The validity lance. Their impact on overall QOL tant in explaining overall QOL: anxi- of the Hospital Anxiety and may be quite significant, and thus, ety, depression, and general health Depression Scale: An updated litera- persons on dialysis should be inten- perception. This finding speaks pow- ture review. Journal of Psychosomatic tionally screened for both disorders. erfully of the mind-body connection. Research, 52(2), 69-77. Assessing for symptoms associated None of the biological, physiological, Centers for Disease Control and Prevention. (2007). Racial differences in with anxiety is especially important functional, or demographic variables trends of end-stage renal disease, by pri- because anxiety may be more preva- adequately explained QOL. In the mary diagnosis: United States, 1994- lent than depression in this popula- end, each person’s sense of internal 2004. Retrieved January 16, 2009, tion. Persons with ESRD are at an emotional equilibrium ultimately from http://www.cdc.gov/mmwr/ added risk for being under-diagnosed determined overall QOL. This con- preview/mmwrhtml/mm5611a4.htm NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1 23
  10. 10. Factors Affecting Quality of Life in Persons on Hemodialysis Cleary, J., & Drennan, J. (2005). Quality Frank, A., Auslander, G.K., & Weissgarten, May, L.A., & Warren, S. (2002). of life of patients on haemodialysis J. (2003). Quality of life of patients Measuring quality of life of persons for end-stage renal disease. Journal of with end-stage renal disease at various with spinal cord injury: External and Advanced Nursing, 51(6), 577-586. stages of the illness. Social Work in structural validity. Spinal Cord, 40(7), Cohen, C.I., Magai, C., Yaffee, R., & Health Care, 38(2), 1-27. 341-350. Walcott-Brown, L. (2006). The Gerstle, D.S., All, A.C., & Wallace, D.C. Merkus, M.P., Jager, K.J., Dekker, F.W., prevalence of anxiety and associated (2001). Quality of life and chronic deHaan, R.J., Boeschoten, E.W., & factors in a multiracial sample of nonmalignant pain. Pain Management Krediet, R.T. (1999). Physical symp- older adults. Psychiatric Services, Nursing, 2(3), 98-109. toms and quality of life in patients on 57(12), 1719-1725. Greene, R.A. (2005). Using the Ferrans chronic dialysis: Results of the Curtin, R.B., Bultman, D.C., Thomas- and Powers’ quality of life index of Netherlands Cooperative Study on Hawkins, C., Walters, B., & Schatell, dialysis: A comparison of quality of Adequacy of Dialysis (NECOSAD). D. (2002). Hemodialysis patients’ life in older and younger African Nephrology Dialysis Transplantation, symptom experiences: Effects on Americans receiving hemodialysis. 14(5), 1163-1170. physical and mental functioning. Topics in Geriatric Rehabilitation, 21(3), Munro, B.H. (2005). Statistical methods for Nephrology Nursing Journal, 29(6), 562- 230-232. health care research (5th ed.). New 574. Harrold, J., Rickerson, E., Carroll, J.T., York: Lippincott Williams & Wilkins. DeOreo, P.B. (1997). Hemodialysis patient- McGrath, J., Morales, K., Kapo, J., et Murtagh, F.E., Addington-Hall, J., & assessed functional health status pre- al. (2005). Is the Palliative Perform- Higginson, I.J. (2007). The preva- dicts continued survival, hospitaliza- ance Scale a useful predictor of mor- lence of symptoms in end-stage renal tion, and dialysis-attendance compli- tality in a heterogeneous hospice disease: A systematic review. ance. American Journal of Kidney population? Journal of Palliative Advances in Chronic Kidney Disease, Diseases, 30(2), 204-212. Medicine, 8(3), 503-509. 14(1), 82-99. Drayer, R.A., Piraino, B., Reynolds, Jablonski, A. (2007). Level of symptom Patel, S.S., Shah, V.S., Peterson, R.A., & C.F., Houck, P.R., Mazumdar, S., relief and the need for palliative care Kimmel, P.L. (2002). Psychosocial Bernardini, J., et al. (2006). Charac- in the hemodialysis population. variables, quality of life, and religious teristics of depression in hemodial- Journal of Hospice and Palliative beliefs in ESRD patients treated with ysis patients: Symptoms, quality of Nursing, 9(1), 50-60. hemodialysis. American Journal of life and mortality risk. General Kalantar-Zadeh, K., Kopple, J.D., Block, Kidney Diseases, 40(5), 1013-1022. Hospital Psychiatry, 28(4), 306-312. G., & Humphreys, M.H. (2001). Phillips, L., Davies, S.J., & White, E. Ferrans, C.E. (1990). Development of a Association among SF36 quality of (2001). Health-related quality of life quality of life index for patients with life measures and nutrition, hospital- assessment in end-stage renal failure. cancer. Oncology Nursing Forum, 17(3 ization, and mortality in hemodialy- Nursing Times Research, 6(3), 658-670. Suppl.), 15-19. sis. Journal of the American Society of Russ, A.J., Shim, J.K., & Kaufman, S.R. Ferrans, C.E. (2005). Definitions and con- Nephrology, 12(12), 2797-2806. (2007). The value of “life at any cost”: ceptual models of quality of life. In Lau, F., Downing, G.M., Lesperance, M., Talk about stopping kidney dialysis. J.J. Lipscomb, C.C. Gotay, & C. Shaw, J., & Kuziemsky, C. (2006). Social Science and Medicine, 64(11), Snyder (Eds.), Outcomes research in Use of Palliative Performance Scale 2236-2247. cancer: Measures, methods, and applica- in end-of-life prognostication. Journal Sesso, R., Rodrigues-Neto, J.F., & Ferraz, tions (pp. 14-30). Cambridge, UK: of Palliative Medicine, 9(5), 1066-1075. M.B. (2003). Impact of socioeconom- Cambridge University Press. Laws, R.A., Tapsell, L.C., & Kelly, J. ic status on the quality of life of Ferrans, C.E. (2006). Quality of life index. (2000). Nutritional status and its rela- ESRD patients. American Journal of Retrieved January 4, 2009, from tionship to quality of life in a sample Kidney Diseases, 41(1), 186-195. http://www.uic.edu/orgs/qli of chronic hemodialysis patients. Smith, K.W., Avis, N.E., & Assmann, S.F. Ferrans, C.E., Cohen, F., & Smith, K. Journal of Renal Nutrition, 10(3), 139-147. (1999). Distinguishing between quali- (1992). Quality of life of persons with Loos, C., Briancon, S., Frimat, L., ty of life and health status in quality narcolepsy. Grief, Loss and Care, 5, 23- Hanesse, B., & Kessler, M. (2003). of life research: A meta-analysis. 32. Effect of end-stage renal disease on Quality of Life Research, 8(5), 447-459. Ferrans, C.E., & Powers, M.J. (1985). the quality of life of older patients. Quality of life index: Development Journal of the American Geriatrics continued on page 55 and psychometric properties. Ad- Society, 51(2), 229-233. vances in Nursing Science, 8(1), 15-24. Ferrans, C.E., & Powers, M.J. (1992). Nephrology Nursing Journal Editorial Board Statements of Disclosure Psychometric assessment of the qual- In accordance with ANCC-COA governing rules Nephrology Nursing Journal Editorial Board statements of disclo- ity of life index. Research in Nursing sure are published with each CNE offering. The statements of disclosure for this offering are published below. and Health, 15(1), 29-38. Ferrans, C.E., & Powers, M.J. (1993). Paula Dutka, MSN, RN, CNN, disclosed that she is a consultant for Hoffman-La Roche and Coordinator of Quality of life of hemodialysis Clinical Trials for Roche. patients. ANNA Journal, 20(5), 575-581. Patricia B. McCarley, MSN, RN, NP, disclosed that she is on the Consultant Presenter Bureau for Amgen, Ferrans, C.E., Zerwic, J.J., Wilbur, J.E., & Genzyme, and OrthoBiotech. She is also on the Advisory Board for Amgen, Genzyme, and Roche and is the Larson, J.L. (2005). Conceptual recipient of unrestricted educational grants from OrthoBiotech and Roche. model of health-related quality of Holly Fadness McFarland, MSN, RN, CNN, disclosed that she is an employee of DaVita, Inc. life. Journal of Nursing Scholarship, Karen C. Robbins, MS, RN, CNN, disclosed that she is on the Speakers’ Bureau for Watson Pharma, Inc. 37(4), 336-342. 24 NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1
  11. 11. Consequences of Chronic Kidney Disease – Mineral and Bone Disorder: A Progressive Disease Quality of Life Virik, K., & Glare, P. (2002). Validation of chronic hemodialysis patients: The continued from page 24 the Palliative Performance Scale for Dialysis Symptom Index. Journal of inpatients admitted to a palliative Pain and Symptom Management, 27(3), Thomas-Hawkins, C. (2000). Symptom care unit in Sydney, Australia. Journal 226-240. distress and day-to-day changes in of Pain and Symptom Management, Williams, A.G., Crane, P.B., & Kring, D.L. functional status in chronic hemodial- 23(6), 455-457. (2007). Fatigue in African American ysis patients. Nephrology Nursing Weisbord, S.D., Carmody, S.S., Bruns, women on hemodialysis. Nephrology Journal, 27(4), 369-379. F.J., Rotondi, A.J., Cohen, L.M., Nursing Journal, 34(6), 610-617. Thomas-Hawkins, C. (2005). Assessing Zeidel, M.L., et al. (2003). Symptom Wilson, I.B., & Cleary, P.D. (1995). role activities of individuals receiving burden, quality of life, advance care Linking clinical variables with long-term hemodialysis: Psychometric planning, and the potential value of health-related quality of life. Journal of testing of the revised Inventory of palliative care in severely ill the American Medical Association, Functional Status-Dialysis (IFS- hemodialysis patients. Nephrology 273(1), 59-65. Dialysis). International Journal of Dialysis Transplantation, 18(7), 1345- Wolfe, F. (2004). Fatigue assessments in Nursing Studies, 42(6), 687-694. 1352. rheumatoid arthritis: Comparative U.S. Renal Data System (USRDS). Weisbord, S.D., Fried, L.F., Arnold, R.M., performance of visual analog scales (2006). USRDS 2006 annual data Fine, M.J., Levenson, D.J., Peterson, and longer fatigue questionnaires in report: Atlas of end-stage renal disease in R.A., et al. (2005). Prevalence, sever- 7760 patients. Journal of Rheumatology, the United States. Bethesda, MD: ity, and importance of physical and 31(10), 1896-1902. National Institute of Diabetes and emotional symptoms in chronic Zigmond, A.S., & Snaith, R.P. (1983). The Digestive and Kidney Diseases. hemodialysis patients. Journal of the Hospital Anxiety and Depression U.S. Renal Data System (USRDS). American Society of Nephrology, 16(8), Scale. Acta Psychiatrica Scandinavica, (2008). USRDS 2008 annual data 2487-2494. 67(6), 361-370. report: Atlas of end-stage renal disease in Weisbord, S.D., Fried, L.F., Arnold, R.M., the United States. Bethesda, MD: Rotondi, A.J., Fine, M.J., Levenson, National Institute of Diabetes and D.J., et al. (2004). Development of a Digestive and Kidney Diseases. symptom assessment instrument for NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1 55
  12. 12. ANNJ0901 ANSWER/EVALUATION FORM Factors Affecting Quality of Life in Persons on Hemodialysis Daria L. Kring, PhD, RN-BC; Patricia B. Crane, PhD, RN, FAHA 1.4 Contact Hours Complete the Following: Expires: February 28, 2011 Name: ____________________________________________________________ ANNA Member Price: $15 Regular Price: $25 Address: __________________________________________________________ Posttest Instructions __________________________________________________________________ • Select the best answer and circle the appropriate letter on the answer grid Telephone: ______________________ Email: _____________________________ below. • Complete the evaluation. CNN: ___ Yes ___ No CDN: ___ Yes ___ No CCHT: ___ Yes ___ No • Send only the answer form to the ANNA National Office; East Holly Payment: Avenue Box 56; Pitman, NJ 08071- ANNA Member: ____ Yes ____ No Member #___________________________ 0056; or fax this form to (856) 589- 7463. Check Enclosed American Express Visa MasterCard • Enclose a check or money order Total Amount Submitted: _________________ payable to ANNA. Fees listed in pay- ment section. Credit Card Number: _______________________________ Exp. Date: _______ • If you receive a passing score of 70% or better, a certificate for the contact Name as it Appears on the Card: ______________________________________ hours will be awarded by ANNA. • Please allow 2-3 weeks for processing. You may submit multiple answer forms in one mailing, however, because of Special Note various processing procedures for Your posttest can be processed in 1 week for an additional rush charge of $5.00. each answer form, you may not ■ Yes, I would like this posttest rush processed. I have included an additional fee receive all of your certificates returned of $5.00 for rush processing. in one mailing. Online submissions through a partnership with HDCN.com are accepted on this posttest at $20 for ANNA members and $30 for nonmembers. CNE certificates will be available immediately upon successful completion of the posttest. Note: If you wish to keep the journal intact, you may photocopy the answer sheet or access this posttest at www.annanurse.org/journal 1. What would be different in your practice if you applied what you have learned from this activity? To provide an overview of factors that affect the quality of life in persons on hemodialysis. ____________________________________________________________ ____________________________________________________________ Please note that this continuing nursing education activity does not ____________________________________________________________ contain multiple-choice questions. This posttest substitutes the mul- tiple-choice questions with an open-ended question. Simply answer ____________________________________________________________ the open-ended question(s) directly above the evaluation portion of ____________________________________________________________ the Answer/Evaluation Form and return the form, with payment, to the National Office as usual. Strongly Strongly Evaluation disagree agree 2. By completing this offering, I was able to meet the stated objectives a. Describe the quality of life in persons with end stage renal disease as found in this correlational, 1 2 3 4 5 cross-sectional study. b. List factors that have been determined to affect quality of life. 1 2 3 4 5 c. Explain how those factors may affect quality of life in persons on end stage renal disease. 1 2 3 4 5 3. The content was current and relevant. 1 2 3 4 5 4. This was an effective method to learn this content. 1 2 3 4 5 5. Time required to complete reading assignment: _________ minutes. I verify that I have completed this activity ________________________________________________________________________________ (Signature) NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1 25

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