Life satisfaction of patients receivingContinuous Ambulatory Peritoneal Dialysis

Item Type text; Thesis-Reproduction (electronic)

Authors Klein, Julie Ellen

Publisher The University of Arizona.

Rights Copyright © is held by the author. Digital access to this materialis made possible by the University Libraries, University of Arizona.Further transmission, reproduction or presentation (such aspublic display or performance) of protected items is prohibitedexcept with permission of the author.

Download date 04/07/2021 08:45:42

Link to Item http://hdl.handle.net/10150/557823

http://hdl.handle.net/10150/557823

LIFE SATISFACTION OF PATIENTS RECEIVING

CONTINUOUS AMBULATORY PERITONEAL DIALYSIS

by

Ju lie Ellen Klein

A Thesis Submitted to the Faculty of the

COLLEGE OF NURSING

In P artia l F u lfillm e n t of the Requirements For the Degree of

MASTER OF SCIENCE

In the Graduate College

THE UNIVERSITY OF ARIZONA

1 9 8 1

STATEMENT BY AUTHOR

This thesis has been submitted in p a rtia l fu lf i l lm e n t of requirements fo r an advanced degree at The University o f Arizona and is deposited in the University Library to be made available to borrowers under rules of the L ibrary.

B rie f quotations from th is thesis are allowable w ithout special permission, provided tha t accurate acknowledgement o f source is made. Requests fo r permission fo r extended quotation from or reproduction o f th is manuscript in whole or in part may be granted by the head o f the major department or the Dean o f the Graduate College when in his judgment the proposed use of the material is in the in terests o f scholarship. In a ll other instances, however, permission must be obtained from the author.

SIGNED: (LLa t %

APPROVAL BY THESIS DIRECTOR

This thesis has been approved on the date shown below:

ALICEMJ. LONGM#^"" Associate Professor o f Nursing

DATE

ACKNOWLEDGEMENTS

The author wishes to express her sincere gratitude to

Dr. Katherine Young and Anne Gassmann fo r serving as members o f her

thesis committee, and fo r th e ir assistance in the guidance o f th is

study.

Special appreciation and thanks are given to the chairperson

o f the thesis committee. Dr. A lice J. Longman, fo r her encouragement,

support and guidance throughout the development o f th is study.

The author also would lik e to extend sincere appreciation to

the s ta f f o f the in s t itu t io n where the data were collected and to

the patients who were so w ill in g to cooperate and pa rtic ipa te in

th is study.

TABLE OF CONTENTS

Page

LIST OF TABLES .................................. vi

LIST OF FIGURES............................................... ' .................... v i i

ABSTRACT...............................................................................................................vi i i

CHAPTER

1. INTRODUCTION . 1

Statement o f the Problem .................................. 2Statement of Purpose .............................................. 2Significance of the P ro b le m ....................... ~ . ...................... 3Conceptual Framework.......................................... 5D e fin ition of Terms ...................................... . 11

2. SELECTED REVIEW OF LITERATURE.............................. 12

L ife S a t is fa c t io n ...................................................................... 12L ife Satis faction of Patients Receiving

Hemodialysis and Renal Transplantation ........................... 15Continuous Ambulatory Peritoneal D ialysis . . ................... 18

3. METHODOLOGY.......................... 22

Research D e s ig n ...................................... ................................... 22S e t t in g ......................................................................................... 22Sample . ................................................................................ . 23Approval fo r the Study ................................... . . . . . . . 23Method of Data Collection .......................................... 23Data Collection Instruments . . . . 24Method o f Data Analysis ........................... 27Lim itations of the Study . . . . . . . . . . .................... 29

iv

V

TABLE OF CONTENTS—Continued

Page

4. PRESENTATION AND ANALYSIS OF DATA . 30

Characteristics of the Sample . . ....................................... 30Results of the Personal Interview ................ 35

Scores and M e a n s ....................... 35Individual Item Scores and M e a n s ............................... .. . 35Verbal Responses.............................................. 40

5. DISCUSSION AND RECOMMENDATIONS . ....................... 47

Findings in Relation to the ConceptualFramework and L ite ra tu re Review . . . 47

C o n c lu s io n s .......................... 52Implications fo r Nursing .......................................................... 52Recommendations . ................................................................. 53

APPENDIX A: LETTER OF APPROVAL FOR STUDY . . . . . 54

APPENDIX B: DISCLAIMER . . . . . . . 55

APPENDIX C: DEMOGRAPHIC SHEET ................. 56

APPENDIX D: PERSONAL INTERVIEW ....................................... 57

APPENDIX E: INTERVIEW CARDS....................................... 59

LIST OF REFERENCES .......................... 60

)

LIST OF TABLES

Page

TABLE

1. Characteristics o f the Sample: Sex and Marital Status . . . 31

2. Sources From Which Subjects Learned o f ContinuousAmbulatory Peritoneal D ialysis . . . . . . . . .................... 33

3. Reasons Subjects Received Continuous AmbulatoryPeritoneal D ia ly s is ...................... . . 34

4. D is tribu tion o f Subjects' L ife Change Scores, D irectiono f Change and Current L ife Satis faction Scores .................... 36

5. D is trib u tion of Each L ife Change Item Total Score, MeanScore and Direction o f Change fo r the Total Sample . . . . 38

6. Mean Scores o f Current L ife Satis faction Ratings ofSelect Groups o f the Sample....................... 39

vi

LIST OF FIGURES

Page

FIGURE

1. Conceptual Framework fo r Study . ...................................... . 10

v i i

ABSTRACT

This study was conducted to describe change in the various

components of the l i f e o f patients receiving Continuous Ambulatory

Peritoneal D ia lysis and to obtain ratings of current l i f e sa tis fa c tion .

An interview was conducted and consisted o f 19 l i f e change items and

one item to measure current l i f e sa tis fa c tio n .

The sample fo r the study was comprised o f 11 subjects. A ll

o f the subjects had experienced change in th e ir lives since receiving

Continuous Ambulatory Peritoneal D ia lys is . Eight subjects indicated

the overall change o f th e ir lives was fo r the better and three

indicated the overall change was fo r the worse. The mean and d irection

o f change fo r each change item in the interview was obtained.

The subjects then selected a number from one to 10 to rate

th e ir current l i f e sa tis fac tion with one ind ica ting low l i f e sa tis

faction and 10 ind ica ting high l i f e sa tis fa c tio n . The range o f the

ratings was from three to 10 with a mean score o f 6.6 fo r the to ta l

sample. Means Of current l i f e sa tis fac tion ratings were compared

between subjects who had been on hemodialysis p r io r to receiving

Continuous Ambulatory Peritoneal D ia lysis and subjects who had not;

married and unmarried subjects; and male and female subjects.

CHAPTER 1

INTRODUCTION

Prior to I960, there was no treatment fo r patients in chronic

renal fa ilu re with end-stage uremia. These patients were c lass ified

as "terminal uremics" and were le f t to su ffe r and die (Abram, 1972).

Patients with end-stage renal disease are now offered the chance to

extend th e ir lives e ithe r through d ia lys is or renal transp lanta tion.

Decisions about the form of treatment tha t o ffe r the pa tien t optimum

survival and q ua lity o f l i f e is made jo in t ly by the pa tien t, fam ily

and physician (T ilney, e t a ! . , 1975; Kress, 1975). Medical and

social factors a ffec ting the patien t should be considered in the

choice o f treatment. Psychological factors should also be considered,

as chronic d ia lys is and transplantation have been shown to be

psychologically s tressfu l to patients who have undergone these forms

o f treatment (Kress, 1975; De-Nour and Shanan, 1980).

From 1960 to 1978, there was only one form o f d ia ly s is ,

hemodialysis, used on a long-term basis fo r the m ajority o f patients in

end-stage renal disease. Studies have shown that hemodialysis

increased the chances fo r survival fo r patients in end-stage renal

disease, but i t also created problems fo r the patient and his family

(Kress, 1975).

1

Another form o f d ia ly s is , Continuous Ambulatory Peritoneal

D ia lys is , was developed by Popvich and Moncrief in 1976 and refined

by Oreopoulos and associates in 1978. With these developments.

Continuous Ambulatory Peritoneal D ia lysis has been accepted and

used throughout the world as a standard procedure o f d ia lys is

(Oreopoulos, 1980). I t is claimed that there are many medical and

psychological advantages fo r patients who undergo treatment w ith

Continuous Ambulatory Peritoneal D ialysis when i t is compared to

hemodialysis and in te rm itte n t peritoneal d ia lys is .

The focus o f nursing in the past has been la rge ly concerned

with the technical procedures o f chronic d ia lys is w ith l i t t l e emphasis

on the q u a lity o f l i f e of the person (Jackie, 1974). Nurses can

assess i f Continuous Ambulatory Peritoneal D ialysis can o ffe r advantages

that may enhance l i f e sa tis fac tion fo r patients receiving th is form of

treatment fo r end-stage renal disease.

Statement of the Problem

How do patients describe aspects o f l i f e change and current

l i f e sa tis fac tion while receiving Continuous Ambulatory Peritoneal

Dialysis?

Statement o f Purpose

The purpose of th is study was to describe l i f e change and

current l i f e sa tis fac tion ratings o f patients who are receiving

Continuous Ambulatory Peritoneal D ia lys is . This study should make

nurses aware o f needs o f patients who are receiving Continuous

Ambulatory Peritoneal D ia lys is ; with th is knowledge, nurses can help

patients adjust to treatment o f Continuous Ambulatory Peritoneal

D ia lys is .

Significance of the Problem

Now fo r the f i r s t time there is a growing population of long

term survivors o f end-stage renal disease who are being maintained

on chronic d ia ly s is . Many refinements have been made in d ia lys is since

1960, when i t was a new and experimental procedure. The m ajority o f

nursing and medical l ite ra tu re , in the past, has been devoted to the

technical improvements and the physiological e ffects o f d ia lys is on

patients. Health professionals working with the d ia lys is population

now perceive tha t th is long-term maintenance therapy has both a

psychological as well as a physiological impact on the lives o f the

patients and th e ir fam ilies .

Hemodialysis has been the treatment of choice fo r the m ajority

Of patients in end-stage renal fa ilu re . From its advent in 1960 u n til

1972, patients were ca re fu lly screened and selected fo r hemodialysis

due to the lack o f fa c i l i t ie s available (Kress, 1975). Hemodialysis

was made widely available to patients in end-stage renal disease by the

United States Government with the 1972 Amendment to the Social Security

Act which helped "to assure that any ind iv idua l who suffers from

chronic renal disease w il l have availab le to him the necessary l i f e -

saving care" (Kress, 1975:41). Another advance was made when Medicare,

in 1973, undertook financ ia l re sp o n s ib ility fo r the treatment of the

m ajority o f patients undergoing d ia lys is (Kress, 1975).

The patient undergoing hemodialysis must adhere to the s t r ic t

regimen he is put on in order to survive (O'Brien, 1980). The regimen

is comprised o f spending approximately s ix hours on the machine three

times a week, d ie tary and f lu id re s tr ic tio n s , taking medications

several times a day and e lim inating some physical a c t iv i t ie s . Patients

on hemodialysis usually have uremic symptoms the day before d ia lys is

such as lethargy, headache, lack o f a lertness, muscle weakness,

nausea, p ru r it is , hypertension and others (Burton, et a l . , 1981).

Continuous Ambulatory Peritoneal D ialysis uses the peritoneum

as the d ia lys is membrane 24 hours a day. Dialysate in two l i t e r

p la s tic bags is exchanged four times a day by the patien t using aseptic

technique. Three o f the exchanges stay in the peritoneal cavity fo r

f iv e hours during waking hours and the fourth exchange stays in the

peritoneal cav ity overnight. The semi-permanent catheter, su rg ica lly

placed in the abdomen, serves to both f i l l and drain the peritoneal

cav ity . The average time required to drain the peritoneal cavity with

the used dialysate and to f i l l the peritoneal cavity w ith fresh

dia lysate takes approximately 30 minutes fo r each exchange (Sorrels,

1979).

There are few d ie tary and f lu id re s tr ic tio n s w ith Continuous

Ambulatory Peritoneal D ia lys is . . Because the d ia lys is process is on

going and the person is maintained in a steady s ta te , d isequilibrium

symptoms disappear tha t are seen with hemodialysis and in te rm itte n t

peritoneal d ia lys is (Oreopoulos, et a l 1979; Moncrief and Nolph,

1980; Oreopoulos, 1980). Other medical advantages seen in patients

receiving Continuous Ambulatory Peritoneal D ialysis are the removal

o f sodium, potassium, small and middle molecules, and water (Oreopoulos

and Katirtzoglou, 1979). Calcium and phosphorus are usually maintained

w ith in normal lim its and patients use minimal doses o f phosphate-

binding oral agents, i f they are needed a t a l l . Blood pressure control

is easier to a tta in with l i t t l e or no use o f anti-hypertensive

medication (Weinman, e t a l . , 1980; Nolph, 1980). Other advantages of

Continuous Ambulatory Peritoneal D ia lysis cited are the omission of a

partner, machine and shunt (Moncrief and Nolph, 1980).

Most patients on Continuous Ambulatory Peritoneal D ialysis

have reported an improvement in well-be ing, an increase in energy,

improved appetite, an increase in a c t iv ity , the a b i l i t y to liv e a more

normal l i f e s ty le and most im portantly, the sense o f freedom that they

experience (Gokel, et a l . , 1980; Sorrels, 1979; Burton, e t a l . , 1981).

Considering the advantages o f Continuous Ambulatory Peritoneal D ia lys is ,

do patients perceive change in various aspects of th e ir lives and how

do they rate current l i f e sa tis fac tion while receiving th is form o f

treatment?

Conceptual Framework

The concepts chronic illn e s s , treatment, l i f e change and current

l i f e sa tis fac tion comprised the conceptual framework. The framework

described the re la tionsh ip tha t treatment of chronic renal fa ilu re

Continuous Ambulatory Peritoneal D ia lysis may have on l i f e change and

current l i f e sa tis fa c tio n .

Quality o f l i f e is an abstract concept to study and define

(Jackie, 1974). In the past, American society has thought tha t

q u a lity o f l i f e could be measured in objective terms o f economic

sa tis fac tion and material possessions and tha t they were the only

important factors fo r human welfare and happiness (Laborde and Powers,

1980; Campbell, 1976). Social indicators such as educational achieve

ment and occupation have been used by social sc ien tis ts to ob jective ly

assess the q ua lity o f a person's l i f e (Laborde and Powers, 1980). I t

was implied by Campbell (1976) that these objective measures may

describe conditions tha t influence l i f e experience, but they do not

assess l i f e experience d ire c tly . Assessment of the q u a lity o f l i f e has

now sh ifted from variables that are material to those tha t are psycho

log ica l and less tangib le. These include variables such as social

prestige, dominance, group id e n tif ic a tio n and sense o f achievement, or

what Mas1ow referred to as the "higher needs" (Laborde and Powers, 1980

Campbell, 1976). •

A major component o f an inc lus ive view o f q ua lity of l i f e is

l i f e sa tis fac tion (Jackie, 1974). L ife sa tis fa c tio n , or a person's

general appraisal of his l i f e , is s p e c if ic a lly defined as

the pleasure one takes from the round o f a c t iv it ie s thatconstitu te his d a ily l i f e , one's perception of his l i f e as meaningful and capable o f continued development, and one's view o f his own s itua tion as sa tis fy in g in terms o f what is and what might be fo r him, in l ig h t o f his own purpose (Jackie, 1974:362).

L ife sa tis fac tion should be a major component of. any comprehensive

conception o f "adjustment" or "mental health" (S e lls , 1969).

I t is not known i f factors can be ranked in importance to one

another when assessing l i f e sa tis fa c tio n . L ife events in which there

are psychological gains and losses .such as b ir th s , deaths, marriages,

accidents, illnesses and unemployment may have a short-term impact on

the way the person appraises his l i f e (Campbell, 1976). When dealing

w ith subjective measures, the ratings may not have the same meaning to

d iffe re n t people and w il l not have the precision of objective ind ica

to rs . However, what they do measure is the in d iv id u a l's sense of

well-being (Campbell, 1976; Jackie, 1974).

Pal more and Lu ikart (1972), in a study o f l i f e sa tis fac tion in

early and middle age, reported tha t se lf-ra ted health was the strongest

variable related to l i f e sa tis fa c tio n . Other variables id e n tif ie d in

th e ir study were social a c t iv ity , socio-economic status and age. They

concluded tha t people who are more sa tis fie d with th e ir lives "tend to

be hea lth ie r, more so c ia lly active , tend to have more income and

education and tend to be younger" (Palmore and Lu ika rt, 1972:68).

Other studies have been conducted to determine i f other

components of l i f e were highly related to l i f e sa tis fa c tio n . These

included m arital sta tus, presence or absence o f ch ild ren, employment

sta tus, sex o f the person, re lationships w ith others and fam ily re la

tionships. These variables were less strongly related to l i f e

sa tis fac tion than se lf-ra ted health (Palmore and Lu ika rt, 1972). The

importance o f the variable o f se lf-ra ted health was s im ila r to the

results o f other studies o f l i f e sa tis fac tion in old age (Neugarten,

Havighurst and Tobin, 1961).

Pal more and Lu ikart (1972) implied that i f se lf-ra ted health

is a highly related variable to l i f e sa tis fa c tio n , then a person's

perception of his health influences his over-a ll op tim is tic or

pessim istic view o f l i f e sa tis fa c tio n . The person's subjective

evaluation o f his health has been shown to influence his l i f e more

than an objective evaluation by a physician. I t was stated "tha t a

person with poor objective health may s t i l l have a high l i f e sa tis fac tion

i f he believes his health is re la tiv e ly good and s im ila r ly a person with

good objective health may have low sa tis fac tion i f he is convinced

his health is re la tiv e ly poor" (Palmore and Lu ika rt, 1972:73). De-Nour

and Czackes (1976) concluded that the pa tie n t's reaction and a ttitu d e

toward illn e ss is influenced by his personality.

Chronic illn e ss may have an impact on a person's view of l i f e

sa tis fa c tio n . The m ajority o f health p rac titione rs assume that the

person who is su ffe ring from a chronic illn e ss does have some type o f

change in varying degrees o f l i fe - s ty le . This may be the re su lt o f the

underlying disease process i t s e l f or the re su lt of the treatment of the

disease. The change may be physiological or psychological involving

a c t iv it ie s that the person may associate with a fu l l and productive l i f e .

Therefore, there may be a reduction in the qua lity of l i f e of that

person (Laborde and Powers, 1980).

Burton, et a l . (1981) stated tha t "o f a ll chronic illnesses,

perhaps no condition is as stressfu l as chronic kidney fa ilu re " (p. 25).

The person undergoing d ia lys is is constantly aware that th is form o f

treatment does replace the function o f his ir re v e rs ib ly damaged

kidneys, but tha t d ia ly s is , in i t s e l f , is not a cure fo r end-stage

renal fa ilu re (Burton, et a l . , 1981; Kress, 1975). The ch ron ic ity o f

th is s itua tion may have an impact on what the patient undergoing

d ia lys is perceives his own health status to be.

There are many sources o f stress fo r patients receiving hemo

d ia lys is . Psychological stressors include dependence on a machine,

dependence on the medical s ta f f or a partner, loss o f mastery of one's

l i f e because the machine is run by others, fru s tra tio n of drives, the

in a b il i ty to plan fo r the fu ture and the fear o f death. Physiological

stressors lis te d in the lite ra tu re are the d ie t, f lu id and physical

re s tr ic tio n s o f the hemodialysis regimen and complications o f shunts

and f is tu la s (B r it is h Medical Journal, 1980; De-Nour and Czaczkes,

1976). These stressors a ffe c t the autonomy o f the person receiving

hemodialysis by re s tr ic t in g his freedom o f choice (Jackie, 1974).

A c tiv it ie s may also be affected by these stressors, resu lting in a

change in l i f e s ty le of the person receiving d ia lys is . The conceptual

model fo r th is study is shown in Figure 1.

According to Dimond (1979), nursing is ju s t s ta rtin g to explore

the p a tie n t's adaptation to chronic illn e s s . Nursing is beginning to

set up models to guide nursing care fo r the patient who requires long

term care. The goal of nursing, when se tting up these models, is to

id e n tify factors which help the person lead a l i f e s ty le as close as

possible to the one he experienced before the onset of the illn e s s .

ChronicIllness

ChronicRenalFailure

Treatment - L ife Change

- Current L ife

Satisfaction

Continuous ________ L ife Change____ ___ Current L ifeAmbulatory Scale ~ SatisfactionPeritoneal ScaleDialysis

Figure 1. Conceptual Framework For Study

In order fo r nursing to reach th is goal, there must be id e n tif ic a tio n

or major variables of l i f e sa tis fac tion important to the person

su ffe ring from chronic disease (Dimond, 1979). The variables of

m arital sta tus, sex o f the person and whether the person has received

p rio r treatment o f hemodialysis need to be id e n tif ie d in the patient

population who is receiving Continuous Ambulatory Peritoneal D ia lys is .

Variations in current l i f e sa tis fac tion ratings may be apparent in the

patient receiving Continuous Ambulatory Peritoneal D ia lysis due to the

influence of these variables.

D e fin ition o f Terms

L ife Satis faction - A person's appraisal o f various components o f his

l i f e .

Continuous Ambulatory Peritoneal D ia lysis (CAPD) - A form o f s e lf-

d ia lys is that the pa tien t has undergone independently

fo r at least two weeks.

CHAPTER 2

SELECTED REVIEW OF LITERATURE

U ntil recen tly , there were few studies about l i f e sa tis fac tio n .

The studies reported were exploratory in nature and tr ie d to define

s ig n ific a n t aspects o f l i f e of people in d iffe re n t populations. Some

studies on th is subject have been conducted on patients on hemodialysis

and very few on patients receiving Continuous Ambulatory Peritoneal

D ia lys is. This review o f lite ra tu re is divided in to three sections:

l i f e sa tis fa c tio n , l i f e sa tis fac tion studies o f patients on hemo

d ia lys is and renal transp lanta tion, and Continuous Ambulatory Peritoneal

D ia lys is.

L ife Satisfaction

According to Campbell (1976), early research studies conducted

on l i f e sa tis fac tion used three major methods to obtain subject

ind icators o f well-being^ In the f i r s t method, the subject was asked

to compare his perception o f his present l i f e s itua tion to a l i f e

s itua tion he aspired to , expected or thought he deserved. The d is

crepancy between his perceived l i f e ra ting and aspired l i f e ra ting would

be used to measure sa tis fac tion or d issa tis fac tion with greater sa tis

faction ind ica ting a sense of well-being.

12

13

The second approach studied subjective fee ling states that

people encountered in th e ir da ily live s . These states were assessed

by the assignment o f numbers to p a rticu la r pos itive and negative events

tha t had occurred in the subjects' lives in the recent past.

The th ird major method was derived from psych ia tric practice.

This strategy consisted o f questions about symptoms, experiences and

general fee lings. Questions regarding l i f e sa tis fac tion re flected

positive responses of well-being and questions regarding worries,

anxieties and emotional crises which re flected negative responses o f

well-being.

Campbell (1976) reported tha t studies were conducted using these

three methods of measurement and reported tha t general sa tis fac tion w ith

l i f e tends to be low among young people and tends to increase with age.

Happiness was reported to be higher in young people and tended to

decrease with age. Happiness with marriage was reported to increase

with the level of education of the subjects, but as the level o f

education increased, feelings of inadequacy as a marraige partner

increased.

Neugarten, Havighurst and Tobin (1961) conducted a study to

describe the psychological well-being of older people. The l i f e s a tis

faction ra ting scale used in th is study was composed o f f iv e components:

1) i f the person took pleasure from everyday a c t iv it ie s o f his l i f e ;

2) i f the person regarded his l i f e as meaningful; 3) i f the person f e l t

he had succeeded in achieving major l i f e goals; 4) i f the person had a

14

positive self-image; and 5) i f the person maintained a happy and

o p tim is tic a ttitu d e and mood. These components were summed to determine

an overall ra ting of l i f e sa tis fac tion fo r each subject.

With these measures, Neugarten, e t a l . (1961) reported that

there was no co rre la tion between l i f e sa tis fac tion ratings and age.

They reported a pos itive re la tionsh ip between l i f e sa tis fac tion and

socioeconomic status. They found that there were no s ig n if ic a n t

differences o f l i f e sa tis fac tion ratings between the two sexes of the

e lderly population. They found lower l i f e sa tis fa c tio n ratings by

people who were not married. This included people who were e ithe r

s ing le , divorced, separated or widowed in both sexes and in both the

older and younger subgroups w ith in the e lde rly population.

Pal more and Lu ikart (1972) conducted a long itud ina l study to

analyze the soc ia l, psychological and physical determinants of

adaptation of people to middle age. Variables measured in th is study

were l i f e sa tis fac tion ra tings , health variables, a c t iv ity variables,

social-psychological variables and socio-economic variables. They

reported tha t older middle-aged people were inclined to be s lig h t ly less

sa tis fie d with l i f e than younger middle-aged people. Pal more and

Luikart also reported tha t employment was a s ig n ifica n t fac to r o f l i f e

sa tis fac tion only to the males in the population studied. They related

that the sex o f the person was the lowest variable related to l i f e

sa tis fa c tio n . I t was also implied in th e ir study that the to ta l number

of social contacts of the population in th e ir study had l i t t l e

significance on l i f e sa tis fac tion ra tings.

Campbell (1976) conducted a study to assess. the q u a lity of

American l i f e . Each subject in the study was given a structured

questionnaire and partic ipated in an interview which consisted of

describing and assessing 15 domains of l i f e . They chose one word

from a pa ir o f adjectives that described th e ir lives with both a

positive and negative connotation. S ign ifica n t variance in measures

o f well-being in th is study was contributed to the factors o f age with

the related variable of l i f e cycle which was the combination of age

with the presence or absence o f marriage and children. Subjects whose

children were grown and were s t i l l married themselves had consistently

high scores o f ind iv idua l well-being. Scores of divorced women were

consistently low and unemployed people reported a s lig h t decrease in

th e ir fee ling of well-being.

L ife Satis faction o f Patients Receiving Hemodialysis and Renal Transplantation

Kemph (.1977) stated tha t the person who is undergoing

hemodialysis faces a compromise in his q u a lity of l i f e . He faces a

reduction in to ta l ca p a b ilit ie s tha t he had p rio r to renal fa ilu re , but

a t the same time he has improvement o f uremic symptoms such as anorexia,

dizziness, seizures, apathy and organic brain syndrome. Laborde and

Powers (1980) stated tha t d ia lys is may increase the pa tie n t's physio

log ica l status so much that the threat o f treatment is'overcome.

In a study by Brown, et a l . (1974) o f l i f e sa tis fac tion o f

patients on hemodialysis, i t was found tha t a ll patients reported a

decrease in physical and emotional well-being described commonly in

16

phrases such as "lack o f energy", "lack o f ambition" and/or a "loss of

in te re s t." Levy and Wynbrandt (1975) studied a group o f 18 patients

on hemodialysis. Several o f these patients reported a drop in th e ir

income and a decline in th e ir fam ily l i f e since they began d ia lys is .

Brown, et al'. (1974) in the same study o f l i f e sa tis fac tion of

patients on hemodialysis described tha t well-adjusted patients on

hemodialysis "tended to minimize th e ir losses and emphasize the

ca p a b ilitie s they s t i l l retained" (p. 68). They tended to understand

th e ir lim ita tio n s and had many varied in terests and a c t iv it ie s that

p rim arily were not physica l. These a c t iv it ie s became important factors

fo r the person who experienced a decrease in physical well-being.

These people tended to understand th e ir financ ia l status and had more

financia l resources and reserves. Well-adjusted patients also led more

active and productive lives because they developed a sense of indepen

dence from the hemodialysis machine.

The less well-adjusted patients on hemodialysis tended to be

much more aware of the decrease in th e ir physical and mental capab ili

t ie s . I t was suggested that th is could have been due to the fac t that

th e ir work and recreational a c t iv it ie s were p rim arily physical p rio r to

the development o f kidney fa ilu re . Levy and Wynbrandt (1975) stated

tha t hopelessness and despair were seen in the less well-adjusted

patients on hemodialysis.

A study conducted by Cantril (1965) compared the ratings of

l i f e sa tis fac tion o f patients on d ia ly s is to a large sample o f the

United States population. Both groups were given a ladder with a

17

number ranging from 1 to 10 on each step and asked to place themselves

on the ladder step tha t they believed they were on fo r past, present

and fu ture l i f e sa tis fac tion scores.

For th e ir present l i f e sa tis fac tion ra tings, the average score

fo r the patien t on d ia lys is was 5.5, half-way between the best and

worst possible l i f e . The normative group o f the United States

population rated th e ir present lives at seven. Rating th e ir lives in

the past, patients on d ia lys is averaged a score near the top o f the

ladder as compared to the normative group, which on the average, rated

the past almost a step below the present. In ra ting the fu tu re ,

patients on d ia lys is rated i t s lig h t ly higher than the present as

compared to a ra ting o f a f u l l step higher by the normative group.

Hope, a component of l i f e sa tis fa c tio n , was displayed by both groups

in th is study by ra ting the fu ture as the same or higher than the

present and not resigning themselves to a de te rio ra ting fu ture (Jackie,

1974).

Levy and Wynbrandt (1975) reported that women were more w e ll-

adapted t o . l i f e on hemodialysis than men. They concluded tha t th is

adjustment may have been due to a more f le x ib le schedule of household

duties and a v a ila b il ity o f others to help as compared to the man whose

employment is usually outside the home. In a study o f compliance of

hemodialysis pa tien ts , O'Brien (1980) found tha t patients who had never

been married had a low compliance score on the d ia lys is regimen, and

tha t patients who were married had a bette r compliance score.

18

Abram (1972). concluded from a study conducted on patients

receiving kidney transplants that th e ir q u a lity o f l i f e was impeded

by th e ir constant awareness o f the underlying chronic renal fa ilu re

and the uncertainty o f the fu tu re . O verall, he concluded tha t patients

who had transplants were sa tis fie d with th e ir lives in general and tr ie d

to liv e them fu l ly .

In view of these factors that may decrease l i f e sa tis fac tion of

patients who are on hemodialysis, Naish (1979) quoted s ta t is t ic s from

the United Kingdom Transplant Annual Report o f 1977-1978 s ta ting that

two-thirds of patients receiving hemodialysis were employed f u l l time

and an additional seven percent worked part time. He also stated that

four out of f iv e successfully transplanted recip ients achieved: the

l i f e s ty le that they hope fo r.

Continuous Ambulatory Peritoneal D ia lysis

In the past, peritoneal d ia lys is was used only fo r patients who

had contraindications to or complications o f hemodialysis (Karanicolas,

1977). With the advent o f Continuous Ambulatory Peritoneal D ia lys is ,

peritoneal d ia lys is may advance to be a major type o f maintenance

therapy fo r patients in chronic renal fa ilu re (F a lle r and Marichal 1980).

Burton, et a l . (1981) reported tha t patients on Continuous

Ambulatory Peritoneal D ia lys is , who carry two l i te r s o f f lu id in th e ir

peritoneal ca v itie s , saw themselves as less in the ro le of sick and

handicapped. These patients tended to be more focused toward l i f e

rather than the life -th re a ten in g menace o f th e ir condition. They

19stated that patients on hemodialysis appeared to spend a ll o f th e ir

energies to stay a live , while patients receiving Continuous Ambulatory

Peritoneal D ialysis could devote th e ir energies toward some o f the

a ttrac tions o f l iv in g .

Oreopoulos, et a l . (1979) stated tha t as soon as patients s ta rt

Continuous Ambulatory Peritoneal D ia lys is , they notice a fee ling o f

well-being. They did not know i f th is is a placebo e ffe c t or i f i t is

due to the physiological factors o f the removal o f small molecules in

the blood such as blood urea nitrogen and creatin ine or the removal o f

unknown tox ic substances that are o f middle molecular size.

Continuous Ambulatory Peritoneal D ia lysis may have advantages

fo r several pa tien t populations. For ch ild ren, in addition to the

treatment being simpler, allowing a better d ie t and giving more freedom

than hemodialysis, i t may also contribute to better growth. Advantages

to persons with diabetes, such as better control o f blood sugar and ’

hypertension, may arrest or improve d iabetic complications (Oreopoulos

and Kartirtzog lou , 1979). This form o f treatment may be useful fo r the

e lde rly pa tien t w ith cardiovascular problems (F a lle r and Marieha1 1980).

Continuous Ambulatory Peritoneal D ialysis does not act as

rap id ly as hemodialysis in acute uremia, hyperkalemia, severe acidosis,

drug in tox ica tion or poisoning (Moncrief and Nolph, 1980). Since

Continuous Ambulatory Peritoneal D ia lysis is s t i l l a re la tiv e ly new

procedure, the long-term e ffects of th is treatment are unknown at th is

time. Studies are being done to determine the long-term effects o f the

20

continual absorption o f glucose and la c ta te ; amino acids may replace

glucose in the fu ture (Moncrief and Nolph, 1980; F a lle r and Marichal,

1980).

P e rito n it is is one o f the main problems seen with Continuous

Ambulatory Peritoneal D ia lys is . The frequency of p e r ito n it is has

decreased from one episode every e ight to 10 weeks to one to two

episodes per year. This decrease was seen with the advent o f use of

p la s tic bags to store the dialysate instead o f glass bo ttles . Most

in fections are due to catheter contamination during bag changes.

P e rito n it is is usually treated by the patien t himself on an outpatient

basis by adding a n tib io tic s to the d ia lys is solution (Nolph, 1980).

Some patients have lo s t the a b i l i t y to lose water through u l t r a f i l i -

t ra t io n . This is seen very often a fte r an episode o f p e r ito n it is in

which there is a decrease o f the peritoneal surface area due to the

thickening of the membrane (Oreopoulos, et a l . , 1981).

Weight gain and hyperlipidemia have been seen in patients

receiving Continuous Ambulatory Peritoneal D ia lys is . F a lle r and

Marichal (1980) reported that 14 patients had an average weight gain o f

5.3 kg when they were treated with Continuous Ambulatory Peritoneal

D ialysis fo r more than three months. They hypothesized tha t th is may

have been due to a better appetite and the amount o f glucose absorbed.

Some contraindications have been lis te d fo r the use of

Continuous Ambulatory Peritoneal D ia lysis by some patien ts. They are

patients who display an unwillingness to learn the technique, a lack o f

s e lf-d is c ip lin e and visual or neurologic problems (Lacke, e t a l . , 1981).

Nolph, e t a l . (1980) stated that there were cu rren tly more

than 670 patients in more than 116 medical centers in the United States

receiving Continuous Ambulatory Peritoneal D ia lys is. I t was also

suggested from reports o f the November 1979 International Symposium on

Continuous Ambulatory Peritoneal D ia lysis that more than 2000 patients

may be undergoing th is treatment in the world (Nolph, e t a l . , 1980).

With the increasing widespread use o f th is form o f treatment, i t is

important fo r nurses to better understand the needs o f these patients

by id e n tify in g change in various aspects of th e ir liv e s .

CHAPTER 3

METHODOLOGY

This chapter consists.o f: the research design, the se tting ,

the sample, approval fo r the study, method o f data co lle c tio n , data

co llec tion instruments, method of data analysis and lim ita tio n s of

the study.

Research Design

This was a descriptive study designed to describe components

of l i f e change and current l i f e sa tis fac tion o f patients receiving

Continuous Ambulatory Peritoneal D ia lys is. This description was

obtained through the semi-structured personal interview consisting of

aspects o f l i f e change and a current l i f e sa tis fac tion ra ting chosen

from a review of the lite ra tu re .

Setting

This study was conducted in a large c ity located in the

southwest. The subjects fo r the interviews were being treated in a

d ia lys is center with a specia lty o f Continuous Ambulatory Peritoneal

D ia lys is .

22

Sample

A convenience sample of 11 patients were interviewed. They

met the fo llow ing c r ite r ia : 1) had a diagnosis o f end-stage renal

disease; 2) were receiving Continuous Ambulatory Peritoneal D ia lys is ;

3) had been undergoing Continuous Ambulatory Peritoneal D ia lysis

independently fo r at least two weeks a fte r the two week ins truc tion

session at the d ia lys is center; 4) were able to understand English;

5) were Caucasian; 6) were 18 years or o lder; and 7) agreed to

pa rtic ipa te in the study. A ll o f the patients in th is sample received

a prescribed two week home tra in ing session on Continuous Ambulatory

Peritoneal D ia lysis at the d ia lys is center a fte r discharge from the

hospital fo r placement o f the abdominal catheter.

Approval fo r the Study

Approval fo r th is study was obtained from the Human Subjects

Committee o f the University of Arizona, the agency where the interviews

were conducted and from each patien t interviewed in th is study. The

study was reviewed and approved as exempt from University review by the

College of Nursing Ethical Review Sub-committee o f the Research

Committee and the D irector of Research. A copy of the le t te r o f

approval fo r th is study is contained in Appendix A.

Method o f Data Col 1ecti on

Four o f the patients were approached fo r the interview when they

reported to the d ia lys is center fo r a monthly scheduled appointment

fo r a tubing change by the nursing personnel. Seven o f the patients

were contacted at th e ir homes fo r the interview . When the patients

24

agreed to pa rtic ipa te in the study, arrangements were made to conduct

and complete the interview .

Data Collection Instruments

The interview schedule was composed o f a d iscla im er, demographic

data sheet and a semi-structured personal in terview .

The cover sheet consisted o f a b r ie f explanation o f the study,

or a disclaim er. Included in th is disclaimer was the r ig h t of the

p a rtic ipan t to ask questions or withdraw from the study at any time

during the interview and the assurance o f privacy to the pa rtic ipan t by

the assignment o f a code number to each subject (Appendix B).

The demographic data sheet was designed by the investiga to r

w ith input from a registered nurse who worked with the patien t

population receiving Continuous Ambulatory Peritoneal D ia lys is . The

demographic sheet consisted of the fo llow ing items: age, sex and

marital status o f the subject, with whom the subject live d , how long

the subject had been receiving CARD, i f the subject had been on hemo

d ia lys is p r io r to s ta rtin g CARD, how the subject i n i t ia l l y learned

about CARD, why the subject was on CARD, i f the subject had complications

while receiving CARD, and i f the subject had any other medical problems

other than end-stage renal disease at the time o f the interview (Appendix

C). These variables were deemed appropriate to th is study. Variations •

in l i f e sa tis fac tion ratings could have been due to the influence of

these variables.

The personal interview was composed of 19 l i f e change items and

one item to measure current l i f e sa tis fac tion adapted from an interview

schedule developed by Young and Longman (1980) fo r patients with cancer.

Subjects were asked to respond fre e ly on how these aspects o f l i f e have

changed since receiving Continuous Ambulatory Peritoneal D ialysis

(Appendix D), The subjects were then handed a card and asked to

indicate the amount of change experienced in each area since they had

received Continuous Ambulatory Peritoneal D ialysis (Appendix E).

Seventeen of the cards had numbers that ranged from 1, which indicated

no change at a l l , to 6, which indicated a great deal of change. I f the

subjects indicated there was a change, they were asked i f the change ■

was fo r the better or the worse and th is was recorded on the bottom

section of the card.

Some modifications were made in the l i f e change items used in

the Young and Longman study (1980). Some items were deleted because

they were deemed inappropriate fo r subjects with end-stage renal disease

or condensed in to broader, more generalized categories, A nurse who

worked with patients receiving Continuous Ambulatory Peritoneal D ialysis

was consulted fo r content v a lit id y o f the items in the interview . The

item, feelings about s e lf , was elim inated from the interview because

th is area was judged to be covered by several other categories such as

physical appearance, s ty le o f dress, physical endurance, sense of

independence, decision making and sense o f achievement. The items,

re lationships with spouse, re lationships with children and re lationships

with inlaws, re la tives were incorporated in to one item, re lationships

with fam ily (spouse, ch ild ren, re la tiv e s ). This new item was judged to

be inc lus ive because the investiga tor did not antic ipate many of the

subjects to be married. The item, re lationships with physician or other

health professionals was modified to read re lationships w ith health

professionals. This was done because the patient who is receiving CARD

works c losely not only with the physician, but also has regular monthly

appointments with nurses and a technician at the d ia lys is center. The

items, re la tionships with associates at work, job performance and job

sa tis fac tion were asked only i f the subject was employed at the time o f

the interview . The item, church or re lig ious group involvement, was

combined with social a c t iv it ie s to form the new item social a c t iv it ie s

(including re lig ious group involvement). The item, social support, was

elim inated from the in terview , as th is was judged to be covered by the

items of re lationships with fam ily , re la tionships w ith health

professionals, re la tionships with friends and social a c t iv it ie s ( in

cluding re lig ious group involvement). The item, changed by treatment,

was omitted from the interview because th is area was judged to be

covered by the new item, change in l i f e sa tis fac tion since CARD began.

The item, thought of stopping treatment, was deleted from the interview

because the patient in end-stage renal disease is dependent on treatment

by d ia lys is to survive. This varied from the o rig ina l in terview by

Young and Longman (1980) in which persons with cancer were asked i f

they thought o f stopping treatment.

The items from the Young and Longman instrument, rate sa tis

faction with current q ua lity of l i f e and rate level of current qua lity

of l i f e were combined in to the new item, current l i f e sa tis fa c tio n . An

example o f the personal interview is contained in Appendix D.

27

Following these adjustments, cards on which the subject

indicated the degree of change fo r each item were given to the subject

fo r 17 out o f the 19 change items o f the interview . Cards were not

given with the two change items, same choice o f treatment and what things

are meaningful to you. Scores fo r each o f the 17 l i f e change item

cards had the range of 1, which indicated no change in the subject's

l i f e , to 6 which indicated a great deal o f change since receiving

Continuous Ambulatory Peritoneal D ia lysis (Appendix E).

Current l i f e sa tis fac tion ratings were also measured with a card

tha t had a score range o f 1 to 10. The score o f 1 indicated low current

l i f e sa tis fac tion and 10 indicated high current l i f e sa tis fa c tio n . An

example o f the two types o f cards used in th is interview is contained in

Appendix E. Each subject was asked to choose the number that closely

measured the degree o f . l i f e change since receiving Continuous Ambulatory

Peritoneal D ialysis fo llow ing discussion o f the item (Appendix E).

Method o f Data Analysis

Scores o f the l i f e change items were tota led fo r each subject

interviewed. I f the subject answered a ll 17 items, the scores could

range from 17 to 102, the la t te r indicated greatest change since

receiving Continuous Ambulatory Peritoneal D ia lysis.

I f the subjects indicated change in a change item o f the

in terview , they indicated i f the change was fo r the bette r or fo r the

worse on the bottom o f the interview card. The number o f items checked

fo r the better were to ta led and the number o f items checked fo r the

worse were tota led fo r each subject. The d irec tion o f the subject's

28

overall l i f e change was determined by the highest number of the sums of

change fo r the better and change fo r the worse. This d irec tion of

change was recorded fo r each subject.

Total scores and means fo r 14 out o f the 19 l i f e change items

of the interview were obtained from the data. This was done to indicate

the degree of change by item in the interview . The number of times

the subjects indicated the change in the item was fo r the be tte r was

recorded and to ta led and the number o f times change in the item was

fo r the worse was indicated was also recorded and to ta led . The d irec tion

o f change fo r each item was determined by the highest to ta l between the

sums o f change fo r the better and change fo r the worse.

Comparisons were made between mean scores of current l i f e

sa tis fac tion ratings of subjects who had been on hemodialysis p r io r to

receiving Continuous Ambulatory Peritoneal D ialysis and subjects who

had not ; between married and unmarried subjects; and between male and

female subjects. Variations in the l i f e sa tis fac tion ratings may have

been related to the variables o f whether the subject had received

hemodialysis p r io r to s ta rtin g Continuous Ambulatory Peritoneal D ia lys is ,

marital status of the subject and sex o f the subject. These variables

may be related to a subject's perception of l i f e sa tis fac tion as

reported in studies conducted in the review of the lite ra tu re . The

verbal comments obtained during the interview were grouped and categor

ized.

Lim itations o f the Study

1. The interview used fo r th is study was modified fo r use by

a d iffe re n t population o f patients in end-stage renal disease receiving

Continuous Ambulatory Peritoneal D ia lys is .

2. The modified interview fo r th is study has not been tested

fo r v a lid ity and r e l ia b i l i t y fo r the population of patients receiving

Continuous Ambulatory Peritoneal D ia lys is.

CHAPTER 4

PRESENTATION AND ANALYSIS OF DATA

The findings and the s ta t is t ic a l analysis fo r the data

co llec tion are presented in th is chapter. -

Characteristics o f the Sample

The convenience sample fo r th is study consisted o f 11 patients

receiving Continuous Ambulatory Peritoneal D ia lysis at a regional

d ia lys is center who met the c r ite r ia fo r the study. There were fiv e

females and s ix males; the age range o f the sample was 25 to 62 years,

with a mean age of 43.5 years. Nine subjects reported tha t they were

married, one was single and one was separated (Table 1). Five o f the

subjects lived with th e ir spouse, four lived with th e ir spouse and

ch ild ren, one lived with a ch ild and one lived with friends.

Seven of the subjects had been on hemodialysis before s ta rting

Continuous Ambulatory Peritoneal D ia lysis and four had not been on

hemodialysis. The range fo r the length o f time that the subjects

received hemodialysis was three months to 120 months with a mean o f 57

months. . The length o f time that the subjects had been receiving

Continuous Ambulatory Peritoneal D ia lysis ranged from one month to 22

months with a mean o f 8.6 months.

30

31

Table 1. Characteristics of the Sample: Sex and M arital Status

Sex: Marital Status:

Male 6 Married 9

Female 5 Single 1

Separated 1

Total 11 Total 11

32

When the subjects were asked how they in i t ia l l y learned about

Continuous Ambulatory Peritoneal D ia lys is , f iv e responded tha t they

learned about i t so le ly from a nurse, two from a physician, one from

the newspaper and magazines and one from a social worker. Two subjects

gave m u ltip le answers. One responded nurse, physician, patients, on

CARD, newspaper and magazines, and medical l ite ra tu re and one cited

nurse, and newspaper and magazines (Table 2). In response to the

question, "Why are you on CARD?", e ight c ited voluntary choice between

CARD and hemodialysis, one stated complications on hemodialysis, one

stated recommendation o f physician and one stated distance to the

d ia lys is center and convenience fo r the fam ily (Table 3).

Seven o f the 11 subjects reported complications since receiving

Continuous Ambulatory Peritoneal D ia lys is . Four have had p e r ito n it is a

to ta l o f seven times, two have had an in fec tion around the catheter s ite

a to ta l of two times and two have had a blockage of the abdominal cathe

te r a to ta l o f three times. Other responses were from two subjects who

have dislodged the abdominal catheter a to ta l o f two tim es, one subject

had bleeding around the catheter s ite one time and two subjects experienced

slow drainage many times the f i r s t two months a fte r s ta rtin g CARD.

Seven of the 11 subjects stated tha t they had medical problems

other than renal fa ilu re a t the time o f the interview . Three subjects

stated they had hypertension, two stated they had diabetes, two had h ia ta l

hernias and two had heart problems. One subject stated hypotension, one

stated scleroderma, one reported lupus erythematosus which was currently

in remission and one subject has become b lind and has had a leg amputation

secondary to diabetes.

33

Table 2. Sources From Which Subjects Learned o f Continuous Ambulatory Peritoneal D ialysis

n = 11

Source Number o f Patients *

Nurse 7

Physician 3

Social Worker . 1

Patients on CAPD 1

Family and Friends 1

Newspaper and Magazines 3

Medical L ite ra tu re 1

* Two subjects named more than one source.

34

Table 3. Reasons Subjects Received Continuous Ambulatory Peritoneal D ialysis

Reason Number o f Patients

Voluntary Choice Between CAPD andHemodialysis 8

Complications on Hemodialysis 1

Recommendation o f Physician 1

Distance to the D ia lysis Center andConvenience fo r Family 1

Total 11

35

Results o f the Personal Interview

Scores and Means

The 11 subjects were interviewed using the personal interview .

The interviews lasted 20 to 90 minutes depending on the ind iv idual

interviewed.

The range o f l i f e change item to ta l scores o f the subjects in

th is study was 21 to 63 with a mean score o f 44.3 (Table 4). Total

possible scores could range from 17 to 102 i f the subjects answered a ll

items; most did not. The mean score fo r the ind iv idua ls ' responses to

the interview items was obtained by d iv id ing the subjects' to ta l scores

by the to ta l number o f items they responded to . The ind iv idua l mean

scores ranged from 1.5 to 4.5, w ith an overall mean o f 3.1 fo r the

sample. Eight o f the subjects indicated the overall d irec tion o f

change in th e ir lives was fo r the better since receiving Continuous

Ambulatory Peritoneal D ia lys is . Three indicated the overall d irection

of change was fo r the worse.

Current l i f e sa tis fac tion ratings were obtained from the sample.

The range o f current l i f e sa tis fac tion ratings o f the subjects was from

three to 10 with a mean score o f 6.6 (Table 4).

Individual Item Scores and Means

Total scores, means, and d irec tion o f change were obtained fo r

14 out o f the 17 items of the' interview . The l i f e change items

concerning employment o f re la tionships with associates at work, job

performance and job sa tis fac tion were not included in th is analysis as

they were only answered by two subjects.

36

Table 4. D is tribu tion o f Subjects' L ife Change Scores, D irection of .Change and Current L ife Satis faction Scores

-

L ife Change Score

L ife Change Mean Score

Direction o f Change

Current L ife Satisfaction Score

63 4.5 Worse 561 4.4 Worse 558 4.1 Better 757 4.1 Better 860 3.5 Worse 346 3.5 Better 542 3 Better 832 1.9 Better 1024 1.7 Better 723 1.6 Better 821 1.5 Better 6

MeanScore:

44.3 3.1 6.6

37

The range of to ta l scores o f the l i f e change items was 20 to

50 (Table 5). The mean scores of the change items ranged from 1.8 to

4.5. The subjects indicated that the overall d irec tion o f change fo r

e ight of the l i f e change items was in the d irec tion fo r the be tte r; the

overall d irec tion o f change fo r three was in the d irec tion fo r the worse

(Table 5).

The l i f e change items of re la tionships with associates at work,

job performance and job sa tis fac tion were answered by two subjects who

were employed at the time of the interview . Both subjects indicated no

change in re la tionships with associates at work. Both subjects indicated

a change in job performance; one indicated a change fo r the better

because he did not t i r e easily with CARD and one indicated a change fo r

the worse as he became tire d more easily since he had begun CAPO. One

subject indicated no change to the item o f job sa tis fac tion and the

other subject indicated a change fo r the worse because he had not been

fee ling w e ll.

Means o f current l i f e sa tis fac tion ratings were compared

between current l i f e sa tis fac tion ratings o f subjects who had been on

hemodialysis p r io r to receiving Continuous Ambulatory Peritoneal

D ialysis and subjects who had not; married and unmarried subjects; and

male and female subjects (Table 6). A mean score o f current l i f e s a tis

faction ratings o f 6.3 was obtained from the seven subjects who had

received hemodialysis previously; a mean score o f seven was obtained

from the four subjects who had not received hemodialysis previously.

Table 5. D is tribu tion of Each L ife Change Item Total Score, Mean Score and Direction of Change fo r the Total Sample *

L ifeChange Item

Physical Appearance Style o f Dress Physical Endurance Sense o f Independence Decision Making Sense o f Achievement Relationships with Family Relationships with Health

Professionals Relationships with Friends Financial S ituation .Hobbies or Recreational

A c tiv it ie s Social A c tiv it ie s (Including

Religious Group Involvement) Change in L ife Satisfaction

Since CAPD Began (Past) Outlook Toward the Future

Totalo f D irection

Scores Mean of Change

34 3.1 Worse35 3.2 Worse45 4.1 Better44 4 Better32 2.9 Better34 3.1 Better36 3.3 Better

26 2.4 Better23 2.3 Better23 2.1 Worse

33 3 Better

20 1.8 Better

50 4.6 Better37 3.4 Better

*L ife Change Items o f Relationships with Associates at Work, Job Performance and Job Satisfaction not included.

39

Table 6. Mean Scores o f Current L ife Satisfaction Ratings o f Select Groups of the.Sample

___________________ _________ (n = ll)

Select Mean Score of CurrentGroup L ife Satisfaction Ratings

Subjects on Hemodialysis Previously 6.3

Subjects Not On Hemodialysis Previously 7

Married Subjects 6.6

Unmarried Subjects 6.5

Male Subjects 6.1

Female Subjects 7

40

A mean score o f 6.6 was obtained from the nine married subjects with a

mean score o f 6.5 by the two unmarried subjects. The mean score o f the

s ix male subjects of the sample was 6.1 and a mean score o f seven was

obtained from the five female subjects.

Verbal Responses

There were varied responses by the subjects in th is study to

each l i f e change item in the in terview . A summary of the responses

fo llows.

The f i r s t l i f e change item dealt with physical appearance.

Four o f the subjects indicated a change fo r the worse c it in g that they

now had a bigger stomach, had gained some weight and tha t the catheter

affected th e ir sexuality and body image. Since they had been receiving

Continuous Ambulatory Peritoneal D ia lys is , four subjects reported no

change and three related a change fo r the better. These subjects

reported tha t th e ir skin color improved and they had regained some o f

the weight they had lo s t p r io r to s ta rtin g Continuous Ambulatory

Peritoneal D ia lys is .

The second l i f e change item dealt with change in the s ty le of

dress. Six subjects c ited there was a change fo r the worse because

they now had to wear baggier clothes, th e ir clothes had to be made

la rger, sh irts were now being worn outside th e ir pants. Most of these

subjects cited tha t they had liked wearing fo rm -fitt in g clothes in the

past but had to give them up now. Three subjects stated tha t there had

been no change in s ty le o f dress. Two stated there had been

41

improvement because they had lo s t a great deal o f weight and th e ir

clothes f i t them since they had gained weight a fte r receiving Continuous

Ambulatory Peritoneal D ia lys is.

Seven o f the subjects' responses to the item of physical

endurance were in the d irec tion o f a change fo r the bette r. One

subject stated there was an improvement due to.an increase in breathing

capacity because he was now keeping f lu id o f f with Continuous Ambula

to ry Peritoneal D ia lys is. Three subjects stated tha t they were doing

much be tte r. One subject stated tha t she had not f e l t th is well in

five years because of progressive kidney fa ilu re and now she did do much

more since receiving Continuous Ambulatory Peritoneal D ia lys is . One

subject stated tha t there had been an increase in physical endurance

the f i r s t few months a fte r beginning Continuous Ambulatory Peritoneal

D ia lys is , but i t cu rren tly was lower than i t was before on hemodialysis

at the time of the interview . One other subject stated tha t his current

level of physical endurance was lower than when he was on hemodialysis

p r io r to receiving Continuous Ambulatory Peritoneal D ia lys is ; two

subjects indicated no change.

The fourth item o f the interview dealt with a sense of in

dependence. The overall response by the subjects was p o s itive , withi

seven subjects sta ting tha t they f e l t much more independent because

they did everything themselves and did not have to depend on others.

One subject stated that his spouse was freed from running the home

d ia lys is machine. Other subjects stated that they traveled much more

. 42

and two subjects stated tha t they re a lly f e l t tied down only when they

did an exchange. Two subjects indicated there was no change and two

indicated there was a change fo r the worse.

Responses to the item of decision making consisted o f four o f

the subjects s ta ting there had been a change fo r the be tte r. One o f

these subjects stated there was an improvement because she f e l t more

secure knowing how to do her own exchanges and that she did not know

how to operate the hemodialysis machine. Five of the subjects

responded tha t there had not been a change. Two subjects responded tha t

there had been a change fo r the worse; one o f these subjects related

that a ll decisions were based around the exchanges.

Change in the sense o f achievement was the s ix th item o f the

in terview . Five of the subjects stated tha t there had been a change fo r

the be tte r. They stated they were getting more done and two o f these

subjects stated they were doing more things now in comparison to when

they were on hemodialysis. Three o f the subjects stated there was no

change and three stated tha t they were not doing the things tha t they

want to do. One o f the subjects stated a great deal o f change fo r the

worse and tha t he only made i t "day to day."

The seventh item dealt with re lationships with fam ily. Five

subjects stated tha t there had been an improvement because they f e l t

better and also because they had more time to spend with th e ir fam ilies .

Four subjects related tha t there had been no change. Two subjects

related there had been a change fo r the worse, and one o f these sub

jec ts c ited tha t he did not go out and do things with them lik e he

used to .

43

The eighth l i f e change item discussed the subjects' re lationships

with health professionals since receiving Continuous Ambulatory Peri

toneal D ia lys is . Seven of the subjects responded there was no change

and that the re la tionships had remained the same. Three subjects

related there was a change fo r the better w ith one s p e c if ic a lly c it in g

tha t i t had been better because she f e l t more independent now that she

was responsible fo r her own care. One subject stated tha t there had

been a change fo r the worse.

Four subjects responded there was change fo r the be tte r fo r the

item o f re la tionships with friends. Reasons cited fo r the change fo r

the bette r were because the subjects had more time to see others and

were able to get out and meet more people. Five o f the subjects cited

no change and one reported a change fo r the worse. Some subjects who

stated tha t there had been no change commented that th e ir friends did

not understand that they were not as free as they used to be, they did

not get around as much and did not see them lik e they used to . One

Subject did not respond to th is item. 1

Eight of the subjects' responses to the item o f financ ia l

s itua tion were no change. One subject stated that Continuous Ambulatory

Peritoneal D ia lysis had been cheaper because o f less hosp ita liza tion .

Two subjects stated the change had been fo r the worse and one subject

c ited an increase in tr ip s to the d ia lys is center. The other subject

c ited he had been unable to work.

The view of most o f the subjects to the item o f hobbies or

recreational a c t iv it ie s was change fo r the better. Five o f the subjects

44

who indicated a change fo r the better c ited the reasons of being able

to travel more and being able to do more a c t iv it ie s . Four subjects

responded that there had been no change and two subjects responded

change fo r the worse.

Eight subjects related there had been no change in social

a c t iv it ie s (including re lig ious group a c t iv it ie s ) since they had been

receiving Continuous Ambulatory Peritoneal D ia lys is . Two subjects cited

a change fo r the better and stated tha t th is was because they were

getting out more and were p a rtic ip a tin g more regu la rly in church

a c t iv it ie s . One subject indicated change fo r the worse.

With the item o f change in l i f e sa tis fac tion since CAPD began,

eight subjects responded change fo r the be tte r. Some o f these subjects

cited tha t there had been an improvement because they were gradually

fee ling worse before receiving Continuous Ambulatory Peritoneal D ialysis

because o f progressive kidney fa ilu re . One subject c ited the change

was fo r the better as he had more freedom and can drink a l l he wanted.

Another subject related the change was fo r the better because of

freedom from the d ia lys is machine. One patient related tha t he was

able to get around much better since receiving Continuous Ambulatory

Peritoneal D ia lys is. Two subjects replied that there had not been a

change and one subject related a change fo r the worse.

Five subjects related that they anticipated change fo r the

better with the item of outlook toward the fu tu re . Most o f these

subjects stated that they f e l t op tim is tic about the fu tu re . Five

subjects did not an tic ipa te change in the fu ture with one o f these

45

subjects s ta ting , " I don't th ink my condition can get any worse." One

subject responded a change fo r the worse because "you don 't look to the

fu ture with th is disease."

Comments from subjects who responded to the question o f ra ting

th e ir current level o f l i f e sa tis fac tion were, " I am very s a tis fie d ,"

" I l ik e my fle x ib le schedule, the hemodialysis regimen was not f le x ib le ,"

" I t 's good and getting be tte r, but there are things I want to do,"

" I t 's better than being on hemodialysis" and " I am in the process of

improving." Other comments received were, " I can 't do things lik e I used

to ," " I t 's not good, because I am not fee ling w e ll," and " I t has

decreased."

The subjects were asked i f they would now choose the same type

o f treatment o f Continuous Ambulatory Peritoneal D ia lys is . Eight o f

the subjects replied that they preferred CAPD and hoped to use i t as

long as they f e l t well using i t . Most of these subjects stated that

they hoped tha t they would not have to go back on hemodialysis. One

subject preferred CAPD to hemodialysis but would prefer a transplant to

have more freedom and con tro l. One subject was fa ir ly sa tis fie d with

Continuous Ambulatory Peritoneal D ia lysis but was not fee ling well and

talked about the p o s s ib ility of going back on hemodialysis. One subject

was not sa tis fie d with Continuous Ambulatory Peritoneal D ialysis

because " i t is a never-ending process, you have a schedule."

The subjects were also asked the question, "What things are

meaningful to you?" Seven of the subjects replied fam ily ; seven o f the

46

subjects c ited staying a live or keep on liv in g ; and four subjects

responded re lig io n . Other responses obtained were frie nd s , recreational

a c t iv it ie s , the need to enjoy the things of l i f e and the accomplishments

that they wanted to make.

A ll of the subjects were receptive to the in terview . They a ll

responded openly to share th e ir personal view of l i f e on Continuous

Ambulatory Peritoneal D ia lys is.

CHAPTER 5

DISCUSSION AND RECOMMENDATIONS

This chapter discusses the findings in re la tion to the conceptual

framework and lite ra tu re review, conclusions, im plications fo r nursing

and recommendations fo r fu ture studies.

Findings in Relation to the Conceptual Framework and L ite ra tu re Review

The concepts o f chronic illn e s s , treatment, l i f e change and

current l i f e sa tis fac tion comprised the conceptual framework fo r th is

study. The conceptual framework described the re la tionsh ip o f treatment

of chronic renal fa ilu re with Continuous Ambulatory Peritoneal D ialysis

may have on l i f e change and current l i f e sa tis fa c tio n . Studies have

shown that the physiological characte ris tics o f a chronic illn e ss may

influence the psychological, social and cu ltu ra l environments of the

ind iv idua l (Dimond, 1980). Change may occur in these areas as a d ire c t

re su lt o f the illn e ss and may a ffe c t the person's adaptation to the

chronic illn e s s . Treatment fo r the illn e ss may diminish or enhance

change in the l i f e o f the patien t. Assessment of change in the pa tien t's

l i f e when receiving a spec ific treatment fo r a chronic illn e ss should

help nurses id e n tify problem areas in the pa tien t's adaptation to the

treatment regimen.

47

48

This study was conducted to describe change in the various

components o f l i f e of patients receiving Continuous Ambulatory

Peritoneal D ia lysis and to obtain ratings o f current l i f e sa tis fa c tion .

A ll of the patients interviewed indicated tha t there had been change in

th e ir lives since receiving Continuous Ambulatory Peritoneal D ia lysis.

The lowest possible to ta l score i f the subject answered a ll items of

the interview o f 17 indicated no change in the pa tie n t's l i f e and the

highest possible to ta l score o f 102 indicated a great deal of change.

The range o f scores obtained from the subjects was 21 to 63 with a mean

score o f 44.3 fo r the patien t sample.

Subjects who indicated change in each item in the interview

were asked to ind icate i f the change was fo r the better or fo r the

worse. Eight of the subjects indicated the overall change in th e ir

lives since receiving Continuous Ambulatory Peritoneal D ia lysis was fo r

the better and three indicated the overall change in th e ir lives was fo r

the worse.

The ind iv idual items of the interview were assessed fo r change

by the to ta l patient sample. The three items with the highest to ta l

score o f l i f e change were change in l i f e sa tis fac tion since CAPD began*

physical endurance and sense of independence and a ll were in the overall

d irection o f change fo r the better. Overall, the subjects indicated

that 11 o f the 14 change items o f the interview were in the d irection

of change fo r the bette r. The three change items o f physical appearance,

s ty le o f dress and financ ia l s itua tion were the items tha t received an

overall ra ting by the population to be in the d irec tion o f change fo r

• 49

the worse. The find ing of change fo r the worse in the item o f financ ia l

s itua tion was s im ila r to a find ing o f a study conducted by Wynbrandt

(1975) o f l i f e sa tis fa c tio n o f patients receiving hemodialysis. The

patients of his study reported a decrease in th e ir income a fte r they

began receiving hemodialysis.

Current l i f e sa tis fac tion ratings were also obtained from the

sample with a scale of 1 to 10 with 1 ind ica ting low current l i f e

sa tis fac tion and 10 ind ica ting high current l i f e sa tis fa c tio n . The

range o f current l i f e sa tis fac tion scores was from 3 to 10 with a mean

o f 6.6 fo r the sample. A study conducted by Cantril (1965) to determine

current l i f e sa tis fac tion o f patients receiving hemodialysis used the

same scale as in th is .study to determine ratings o f current l i f e s a tis

fac tion . The Cantril study revealed tha t the average score o f current

l i f e sa tis fac tion of a sample o f patients receiving hemodialysis was 5.5

and a sample o f the normative population o f the United States population

had an average score o f seven. Using these ind ica to rs , the mean score

o f current l i f e sa tis fac tion o f 6.6 of the subjects who received

Continuous Ambulatory Peritoneal D ia lysis in th is study resembled the

current l i f e sa tis fac tion ratings o f the normative group o f the United

States population more closely than the ratings o f the patients

receiving hemodialysis in the Cantril study. This find ing resembled

the find ing by Burton, et a l . (1981) that patients who received

Continuous Ambulatory Peritoneal D ia lysis saw themselves as less in

the ro le of sick and handicapped.

50

The results of th is study showed tha t the overall d irec tion o f

l i f e change in the subjects' lives may have a re la tionsh ip with th e ir

perception o f current l i f e sa tis fa c tio n . Three out of the four subjects

who indicated the lowest l i f e sa tis fac tion scores were the three

subjects o f the sample who indicated that the overall change o f th e ir

lives was fo r the worse.

A great deal of change may have affected the overall d irection

o f change o f the subjects' liv e s . This was supported by the find ing

th a t three o f the five highest l i f e change scores and ind iv idua l l i f e

change mean scores were from the three subjects who indicated an overall

change fo r the worse in th e ir live s .

Means o f current l i f e sa tis fac tion ratings were compared between

subjects on hemodialysis p r io r to Continuous Ambulatory Peritoneal

D ia lysis and subjects who had not; between married and unmarried

subjects; and between male and female subjects. A higher current l i f e

sa tis fac tion ra ting mean was obtained by the subjects who had not

received hemodialysis p r io r to Continuous Ambulatory Peritoneal

D ia lys is , by the married subjects and the female subjects o f the sample.

The findings o f a higher current l i f e sa tis fac tion mean rating

by the married patients were s im ila r to the results o f the l i f e

sa tis fac tion study of old age conducted by Neugarten, et a l . (1961).

They related that lower l i f e sa tis fac tion ratings were reported by

unmarried people in th e ir sample. A higher mean ra ting score o f current

l i f e sa tis fac tion by the female subjects in th is sample correlated w ith

the results o f a study conducted by Levy and Wynbrandt (1975) of

patients on hemodialysis. They reported tha t women were more w e ll-

adapted to l i f e on hemodialysis than men.

C antril (1965) reported that in his study of l i f e sa tis fac tion

of patients receiving hemodialysis and a sample o f the normative

population o f the United States that hope, a component of l i f e sa tis

fac tion , was displayed by both groups. This was measured by ra ting the

future as the same or higher than the present and not ind ica ting that

they were resigning themselves to a de te rio ra ting fu tu re . This was

also seen in the sample o f th is study; f iv e subjects indicated a change

fo r the better fo r the fu tu re ; f iv e subjects did not. an tic ipa te a change;

and only one subject anticipated a change fo r the worse.

The eight subjects who indicated tha t the overall change in

th e ir lives was fo r the better a ll responded that they would now choose

the same type of treatment o f Continuous Ambulatory Peritoneal

D ia lys is . Of the three subjects who indicated the overall change in

th e ir lives was fo r the worse, two subjects indicated tha t they might

chose an a lte rna tive therapy and one of these subjects stated that he

had not f e l t well shortly a fte r receiving Continuous Ambulatory Peritoneal

D ia lys is. The th ird pa tient responded tha t he did not lik e the

continuous ongoing regimen of Continuous Ambulatory Peritoneal D ia lys is.

In summary, the treatment of Continuous Ambulatory Peritoneal

D ialysis did a ffe c t the lives o f a ll o f the subjects in th is study.

This form o f treatment affected various aspects of the subjects' lives

and possibly th e ir perception o f l i f e sa tis fa c tio n .

52

Conclusions

Few so lid conclusions can be drawn from th is study. From th is

study, i t can be suggested that a pa tient may experience change in his

l i f e when receiving Continuous Ambulatory Peritoneal D ia lys is . The

change may be fo r the better in some areas, depending on the circum

stances o f the in d iv id u a l. From th is study, nursing can be aware that

patients may encounter some d i f f ic u l t y in adjustment in the areas of

physical appearance, s ty le o f dress and financ ia l s itua tio n when

receiving Continuous Ambulatory Peritoneal D ia lys is.

Implications fo r Nursing

An unexpected find ing of th is study was that of the seven

subjects who indicated tha t they in i t ia l l y learned o f Continuous

Ambulatory Peritoneal D ia lys is from a nurse; five lis te d a nurse as

th e ir primary source. Nurses should be aware o f the importance of

th e ir ro le as a member o f the health care team in the area o f patient

education fo r advancements in medical treatments.

Nurses should also be aware tha t the person who w il l be

receiving Continuous Ambulatory Peritoneal D ialysis may experience

change in various aspects o f his l i f e . These changes may a ffe c t the

person's adaptation to l i f e on Continuous Ambulatory Peritoneal

D ia lys is . This information can serve as a foundation fo r nurses to

assess and plan interventions fo r these patients. Nurses who are aware

o f these changes can id e n tify and discuss problem areas with patients

p r io r to and pe riod ica lly a fte r receiving Continuous Ambulatory Peri

toneal D ia lys is.

53

Recommendations

1. Further tes ting o f the modified personal interview used in th is

study fo r v a lid ity and r e l ia b i l i t y .

2. Use o f a larger sample to make the results more generalizable.

3. Conduct a longitud ina l study of patients when they in i t ia l l y begin

receiving Continuous Ambulatory Peritoneal D ia lysis and s ix months

la te r. .

4. Conduct a study comparing current l i f e sa tis fac tion ratings and

degree o f l i f e change between patients receiving Continuous

Ambulatory Peritoneal D ia lysis and patients receiving hemodialysis.

APPENDIX A

LETTER OF APPROVAL FOR STUDY

THE UNIVERSITY OF ARIZONA COLLEGE OF NURSING MEMORANDUM

TO: Julie Klein____________________ -_

250 N. Arcadia #1113, Tucson 85711

FROM: Ada Sue Hinshaw, R.N., Director of Research

Ph.D. - Margarita Kay, R.N., Ph.D.Chairman, Research Committee

DATE: October 12, 1981

RE: Human Subjects Review: "Life Satisfaction of Patients Receiving

Continuous Ambulatory Peritoneal Dialysis"

Your project has been reviewed and approved as exempt from University review by the College of Nursing Ethical Review Su