Who will protect the "disruptive" dialysis patient?

I. INTRODUCTION "There is an art to being a patient. Sometimes you must ask the hard questions and at other times, you must put your faith in the hands of another human being. In some way, doctors and their patients are partners. Some patients are good at it. Other patients get in their own way. It's like a dance." ' How common is the disruptive dialysis patient? Are outpatient dialysis centers equipped to handle such patients, especially when they only use threatening words? At what point can it be said that the involuntary discharge of such patients is warranted? What happens to these patients? If they find legal representation, under what legal authority may they continue to be treated? This article revolves around the difficult situation of a particular patient with end stage renal disease. Although this condition is fully covered by Medicare, the patient was banned from all access to dialysis care in the outpatient setting. His caregivers regarded certain comments he made as so dangerous and threatening that he was discharged from that facility, and every other facility in his geographical area. With no options in sight, a treating hospital arranged for his care in its inpatient facility. Although the treating hospital saved his life, it was an undesirable solution for both the hospital and the patient. The patient was unable to find an outpatient dialysis home despite assurances to potential facilities that his support network would participate in his care, and despite a court's finding that he presented no danger to his current caregivers. The patient's situation only improved after he received a kidney transplant. This Article relates the challenges of representing such a client and discusses the current debate in the dialysis industry. The Centers for Medicare and Medicaid Services' proposed Conditions for Coverage for End Stage Renal Facilities raise the question of the need for relevant regulations to be more patient-centered. The few legal cases that have been reported concerning such plaintiffs are examined. The Article concludes that private dialysis centers should not be free to dismiss their patients from care when their "disruptive" behavior may be addressed via certain accommodations by the facilities. Involuntary discharge must not occur without strict prerequisites, such as consent by the patient's treating nephrologists and documentation of efforts to resolve the situation. Most dialysis chains are for-profit operations with healthy profit margins. They are situated, owing to a regular stream of Medicare funding, to maximize the talents in each of their centers in the form of interdisciplinary staff, and to face the challenges posed by the most difficult patients.2 The support and direction provided by the Renal Care Networks make it possible for even the most difficult patients to be treated without jeopardizing the safety of other patients and staff. No dialysis patient should receive a death sentence. II. THE STRESSES OF BEING A DIALYSIS PATIENT "Upon hearing his name, Robert pitched his paper and walked to his recliner, past a score of patients tethered to blinking, beeping machines. Two thin plastic tubes, reddened by steady streams of blood, snaked from each of the patients' forearms. On their inner arms, dialysis patients have knots called fistulas, where doctors connect a vein and an artery to enable them to receive dialysis. The arterial tube feeds blood into the dialyzer, where a six-inch filter composed of dozens of strawlike tubes draws out wastes the kidneys can no longer expel. The cleansed blood is then pumped back into patients' bodies. Without dialysis, Robert and the other patients would die within a few weeks."3 A. DIALYSIS Almost 309,000 people were chronic kidney dialysis patients in the United States as of December 31, 2002, the last date for which data is available.4 Since the early 1970's, Americans suffering kidney failure, or End Stage Renal Disease (ESRD), have been afforded coverage for this lifesaving technological procedure. …