N23 — Missed Treatments: Understand the Barriers

When: A missed or shortened treatment, repeated late arrival, or a patient who says dialysis is becoming hard to manage.

Do this

1. Check safety: confirm the last completed treatment, current symptoms, and whether the patient is hospitalized or dialyzing elsewhere. Notify the clinician and coordinate the next treatment under unit policy [1].
2. Meet them where they are: ask privately, 'What got in the way?' Listen without blame. Acknowledge the difficulty and ask which barrier they want help with [2].
3. Explore rides, work/caregiving, food/housing/utilities, costs, communication/support, and how dialysis makes them feel. Pain, cramps, fear, fatigue, and recovery burden need clinical attention too [2,3,4].
4. Agree on one achievable action. Make a direct handoff to the appropriate team member; name an owner, follow-up time, and backup plan. Confirm the treatment slot and transportation when needed.
5. At the next contact, ask whether the plan worked. Record the patient's stated barrier, agreed help, and unresolved needs; a referral alone is not resolution.

Call / escalate

• Severe breathlessness, chest pain, syncope, confusion, or concerning weakness/palpitations: urgent clinical assessment under the emergency pathway. Feeling well does not prove it is safe to wait after missed dialysis [1].
• Unsafe discharge situation, immediate safety threat, suicidal intent, or no feasible plan for needed dialysis: escalate promptly through the unit's clinical and social-support pathways.

Don't

• Do not shame, threaten, or assume the patient does not care. Do not label declined help or an unanswered call as 'no need.'
• Do not independently change dialysis, increase UF to make up missed time, or assume home dialysis solves the barrier.