End of the Summer Schedule Changes

September has a way of sneaking up on me every year. Just when I feel like I’ve gotten used to the slower cadence of summer, it ends.

My personal schedule always shifts at the end of summer to accommodate everyone else’s again. I go back to setting a 6 a.m. alarm because my natural wake-up time of 7 a.m. doesn’t leave enough time to get my kids up, moving, out the door, and off to school. There are regular morning traffic jams for the shower at my house when school starts. My dogs quickly learn to expect and whine for their breakfasts earlier. The quiet, hot cup of morning coffee I used to savor on my porch alone is replaced by an abandoned, lukewarm cup on the counter in the morning hustle as we rush around and configure ourselves for the day.

Once the school year starts, the days have a new rhythm. The evenings fill with activities. Similar shifts happen in lots of homes, including busy homes where home dialysis is also a factor in the schedule. A routine that may have worked beautifully in July can absolutely fall apart by October if dialysis is not considered in the overall life plan of the household. Dialysis can feel harder to fit into a busy life when life suddenly gets more demanding. We can help prepare for these seasonal changes by recognizing the pattern and acknowledging that home dialysis routines do not necessarily have to look the same all year long.

Home Is Supposed to Be Flexible

One of the biggest advantages of home dialysis is the flexibility. There is no set treatment chair time to which a person must adhere to three times per week every week indefinitely. At home, it doesn’t matter if dialysis happens at 7 a.m. or 7 p.m., it just matters that it happens safely, consistently, and often enough to meet the person’s needs.

Another one of HHD’s benefits is that there are no set schedule requirements at home. For many home patients, dialysis can happen any day of the week, or even every day as long as treatments are run safely and consistently throughout the week. Home treatment also can make it easier to avoid dangerous gaps between treatments that are built-in to traditional clinic schedules.

Home HD offers flexibility in another way, too. Not every home HD schedule has to look alike. Prescriptions can vary tremendously depending on what the person, their clinical needs, and what they want their treatments and lives to look like.

Some people do very well with short, frequent treatments. They dialyze more often than three times per week, but usually for shorter sessions. I have known people who prefer the routine of true daily treatments because dialysis becomes a stable, steady, and predictable part of daily life. There is less mental negotiation about whether or not today is a “dialysis day” if every day is.

Other people prefer having a couple of days off and accept the tradeoff of longer treatment times for fewer treatment days.

Personally, I do not think anyone at home should dialyze less frequently than every-other-day to avoid two-day treatment gaps. One of the greatest advantages to being home is there is no entrapment by the Monday-Wednesday-Friday or Tuesday-Thursday-Saturday clinic routine, so this is very possible to achieve.

And Then There Is Nocturnal Home HD

I will be the first to admit that I have a soft spot for nocturnal dialysis. It’s so gentle. When a person can manage it, nocturnal home HD is probably the best dialysis we can provide.

As a new home dialysis nurse, my mentors were almost evangelical about the benefits of nocturnal home HD. I can still hear the phrase: “We always have to give them phosphorus back!” At the time, it sounded absurd because I had come from the clinic, where absolutely no one needed phosphorus added back. Dialysis patients were constantly told to strictly limit foods and take binders in the clinic. Yet patients doing long, frequent, overnight dialysis could basically eat whatever they wanted and sometimes remove so much phosphorus the challenge became preventing it from falling below normal limits.

That is a profound and fundamental difference between modalities that stuck with me. It was unforgettable. Those of us who have had the opportunity to see people truly thrive on long-term nocturnal dialysis quickly become believers in my experience. Patients enjoy the health benefits of gentle fluid removal, more time for solute clearance, and the ability to wake up and have little to no post-dialysis recovery time to hinder the rest of the day.

But nocturnal dialysis is not right for everyone, either.

Hybrid Home HD Schedules

And that brings me to an approach that I suspect happens in real life far more than it is formally discussed: hybrid home HD schedules. We already know shorter, more frequent treatments can work. We know longer treatments can work. We know nocturnal dialysis can work. So, why should we assume that every treatment a person does has to be the same? What about people who would benefit from a combination of these approaches?

I once cared for a patient who was a professor. She had two homes and divided her time between them according to the academic year. Summer belonged to the lake house. When I say she enjoyed the lake life, I mean she really enjoyed the lake life. She boated. She liked to beachcomb along the shore. She rode horses. She went golfing. She had long dinners with friends. She lived for good food, good wine, live music, late nights, and sleeping in the next morning. She had very little interest in continuing dialysis if it was going to interrupt any of those plans.

So, when she was at the lake for the summer, she did nocturnal treatments. Dialysis happened while she slept, leaving her days largely her own. She also had more room to eat and drink in ways that fit her laid-back summer life.

Then the school year would start. My patient would return to her other home and her life would change completely for a few months. During the academic year, she taught during the days and spent her evenings reading, writing, preparing lectures, and grading papers. I can still picture her life as if it were on a postcard, with her fireplace, dog, papers, and books.

During those months, dialysis became part of her academic routine instead. Rather than giving up her bed to nocturnal treatments, she did long and frequent treatments in the evenings while she worked. She could answer emails, read, grade papers, work on projects, and prepare for class while she did treatment. Dialysis became part of the work she was already doing. It was an excellent example of multitasking.

Different seasons of life, and different treatments to match. I loved that. Her dialysis routine was built around the life she was actively living. It is a story I still tell because it changed the way I think about what a home HD prescription can look like.

What Could a Hybrid Schedule Look Like?

Some people may need even more flexibility than a summer vs. school-year schedule. A hybrid home HD plan might include:

• A short treatment on a particularly busy day.

• A longer treatment on a day that ends early.

• More frequent or daily treatments during one part of the week.

• A late-night or nocturnal treatment when the morning is open.

• Different treatment lengths on different days of the week.

• Adjusting the routine temporarily when work, school, travel, or other life demands change.

I’m not saying anything goes, or that it should be fine to have a “free-for-all” schedule. It’s clinically much more complicated than that. Dialysis frequency, treatment time, dialysate composition, volume or flow, blood flow rate, fluid removal limits, vascular access type and needle size—all of it, is prescribed. And all of those parameters are prescribed for a reason.

Sometimes the Software is More Rigid Than the Patient

I remember the electronic medical records system I used to work with at the clinic. There was only one tidy place to enter the treatment orders. This is likely because in-center dialysis prescriptions are rigid. Dozens of people need to move through on an organized schedule, so treatment is standardized to be time efficient. Home is inherently different.

For my professor patient whose orders changed with the academic calendar, her life was more flexible than the software allowed. I had to make whichever schedule she was currently using the “primary order” and then document the alternate “secondary order” schedule in a comment so I could switch it back when she moved between homes. It did the trick, but I will admit it was an annoying workaround.

Home HD prescriptions can be individualized relatively easily. A home HD prescription has much more room to adjust. And an experienced, informed home HD patient may be able to work with their care team to think about dialysis across the whole week rather than assume every treatment is a replica of the treatment before it.

Flexibility Requires Better Education

This requires more education than teaching patients how to set up a machine and run a treatment. It requires helping patients fully understand why they are doing what they are doing. By giving options and clarifying the physiology behind the dialysis schedule, the prescription stops being a mysterious set of parameters and becomes a conversation patients can meaningfully participate in.

That becomes especially important when life changes, even in ordinary ways. For example, work gets slightly busier, a grandchild joins the football team, or someone is asked to pick up an extra shift at work. Life can change simply because the weather is nice and people feel like spending more of their waking hours outside enjoying it instead of inside attached to a dialysis machine.

Make the Prescription Fit the Life

The default solution for when the schedule does not fit should not automatically be to skip treatment or cut the time short. A better way of dealing with these things is to think about how the prescription can work better for the patient and their current life while still providing enough dialysis. Home dialysis can make that possible and promises people more freedom and control over how kidney failure impacts their life. But, it cannot do that if the rigid in-center schedule is transposed over to a patient’s house, or if patients are never given enough education or flexibility to safety adapt their treatments with their care team. That is a missed opportunity.

The goal of home dialysis should not be to make life fit around dialysis by whatever means necessary. It should be to find ways to help fit dialysis into an existing life. Sometimes that means being open to treatments looking different, even for the same person in different seasons of life.