Such a program is sorely needed. It depends. But opting out of some of these cookies may have an effect on your browsing experience. In fact, it often worsens their quality of life. She is the author of Hundreds of Interlaced Fingers: A Kidney Doctor’s Search for the Perfect Match. Automated peritoneal dialysis. In fact, it often worsens their quality of life. - Scottish charity no. Kate Meyers They will be able to give you advice and suggest other forms of support. I started with the nurse practitioner. Dialysis can be a burdensome treatment, and may reduce quality of life, particularly in patients with other medical conditions. Dialysis is a procedure that performs many of the normal duties of the kidneys, like filtering waste products from the blood, when the kidneys no longer work adequately. Vanessa Grubbs, MD, is a nephrologist who changed her focus from practicing medicine to writing. Dialysis doesn’t stop your kidney function deteriorating further; in fact, it can sometimes make it get worse more quickly. You do not have to wake up at night to do an exchange. - HealthDay Reporter. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. If you are considering active supportive care your doctors will respect your views but you may also want to talk to your family about the decisions you and your medical team are considering. section. Not recommended for patients with severe hepatic impairment. If dialysis is a treatment option for you, your doctor will discuss the risks and benefits, as well as optimal timing. Outpatient palliative care is virtually nonexistent, and hospice providers haven’t figured out how to meet the needs of patients with kidney failure. Sometimes people find dialysis too difficult and wish to stop after a short or a long time. Kidney Research UK, Nene Hall, Lynch Wood, Peterborough PE2 6FZ. Dialysis can then be started in an unplanned way. She went on to an exasperated, “Why does he keep coming back here if he doesn’t want dialysis?”, Because she was new to nephrology and the care of patients approaching end-stage kidney disease, I shook my head in disappointment, thinking, “They got to her first.”. But being prepared and understanding all types of dialysis access means you can feel confident in the choice you and your doctor make. Because they believe dialysis always prolongs life, and prolonging life is all that matters. These cookies do not store any personal information. In patients with reduced renal function, GCBA exposure increases the risk of NSF. We also use third-party cookies that help us analyze and understand how you use this website. More frequent dialysis,medicines,a kidney transplant and closely monitored care may improve a woman’s chances of having a baby while on dialysis. WebMD Medical Reference Reviewed by Minesh Khatri, MD on December 07, 2020 Sources Your doctor may also suggest involving other professionals such as a social worker or a counsellor to help support you and help you decide what is right for you. One study found that elderly people who had dialysis lived on average a year longer than those who didn’t — but almost all of this added time was spent in the hospital, traveling to and from dialysis, or undergoing dialysis treatments. On HD days, administer after dialysis. They tell patients, “Start dialysis, or you’ll be dead in two weeks” or “You have a responsibility to your grandchildren to be here.” They even say, “Just try it, and if you don’t like it you can stop,” without offering a vision for what they hope dialysis can do and by when. Dialysis is a treatment that filters and purifies the blood using a machine. protecting and maintaining your remaining kidney function so you remain as well as possible for as long as possible, anticipating and preventing any situation where your kidneys are put at more risk, eg when the weather is really hot and you might find it harder to maintain your fluid balance, treating symptoms and complications of kidney disease. Take a look at our Dialysis Decision Aid booklet. Some kinds of acute kidney failure, also known as acute renal failure, get better after treatment. She had spent the last hour with a 75-year-old man with severe chronic kidney disease. You may wish to speak with your religious advisor if you have any concerns about this. The recommended dose is XARELTO 2.5 mg twice daily plus aspirin (75-100 mg) once daily. A machine does the exchanges while you sleep. By Robert Preidt. DIALYSIS Definition- Dialysis is a technique in which substances move from the blood from semi permeable membrane and into a dialysis solution. It can really help to get your family involved in these conversations too. Experience has given me different lessons. After taking these and other factors into consideration, some people choose not to start dialysis but instead opt for active supportive care (sometimes known as conservative, maximum conservative or responsive care). It’s difficult to be accurate about life expectancy, as this will depend on your general level of health, how much kidney function you have left, your diet, the speed of your kidney disease progression, and whether you have any other serious medical conditions. Necessary cookies are absolutely essential for the website to function properly. These periodic reviews called care team meetings include input from your husband and you and help the care t… I was the supervising nephrologist, so I asked her how things were going with the patient. Eat a piece of cold or frozen fruit, like grapes, strawberries or blueberries. Bathing and swimming not recommended; Higher risk of clotting and infection; Getting to the point where you have to seriously consider dialysis can be a scary time. For instance, a patient with ESRD and cancer may want to forgo dialysis because it will prolong pain and suffering. To make dialysis patients live easier, they are recommended to eat correct foods and drink correct juices. Dialysis can help with symptoms caused by kidney failure, but if you have other medical conditions, eg stroke, Parkinson’s disease, peripheral vascular disease, frailty, or dementia, dialysis won’t help with the symptoms that they cause, and could even make them worse. Senior Program Officer, High-Value Care, Jennifer Moore Ballentine Testing conducted at dialysis facilities should be implemented in addition to recommended IPC measures. PD is a relatively gentle but effective dialysis technique, and is often recommended for people starting out on dialysis. PURPOSE The purpose of dialysis is to maintain fluid electrolyte and acid base balance and to remove endogenous and exogenous toxins 11. Kidney Research UK is a registered charity no. You can also find information about other forms of support, together with advice on managing your medications and taking care of your mental health in our How can I help myself? No dosage adjustment is needed based on CrCl. If your husband's dialysis care team doesn't periodically review his overall situation, ask for a review. People like Mrs. N, an 88-year-old woman whose kidneys filtered only one teaspoon of blood each minute when I met her. Meeting with a palliative or supportive care team to help you make advanced care plans to ensure you get the care you want when your health deteriorates. The CDC recommends that the catheter not be submerged in water, and it is not recommended to swim, shower, or soak catheter dressings while bathing. If you find this is the case, your team will respect your wish to stop. Then, what juices dialysis patients need to avoid? 3 252892. Several European studies have shown that dialysis does not guarantee a survival benefit for people over age 75 who have medical problems like dementia or ischemic heart disease in addition to end-stage kidney disease. Contact your physician or dialysis nurse for additional recommendations. '” She tilted her head and nodded in that way we clinicians do when we think we’ve summoned the courage to say what needed to be said. In some cases of acute kidney failure, dialysis may only be needed for a short time until the kidneys get better. looking after your mental and spiritual wellbeing. This website uses cookies to improve your experience while you navigate through the website. It is a good idea to discuss this question with your kidney doctor. -Doses should be taken at the same time each day. In this same age group, in more advanced stages of CKD (Stage 3-5, eGFR <60 mL/min/1.73 m 2), treatment with combination statin plus ezetimibe is recommended. If dialysis is recommended for you, you'll often be able to choose whether to have haemodialysis or peritoneal dialysis. Speak With Your Doctor His kidneys were filtering about 4 teaspoons of his blood every minute when normal is 25 teaspoons. It is for patients like Mrs. N that I have been working to create a conservative management program as part of the nephrology clinic at Zuckerberg San Francisco General Hospital. All Rights Reserved. This involves working closely with you to treat the symptoms of end-stage kidney disease (ESKD), and continuing active treatment to ensure that your kidneys can work for as long as possible to give the best possible quality of life. The nurse practitioner exhaled completely as she plopped down next to me in the clinic workroom — as if she had used up her last bit of energy. Your medical care will normally be managed by your kidney doctors together with your GP, whose role – like that of the district nurse – may increase if your kidney failure gets worse and you require a greater level of end of life care. You may receive care in hospital, at home or in your local community (for example, day care services at your local hospice). These cookies will be stored in your browser only with your consent. SC039245. Tunneled cuffed catheters, a type recommended by the NKF for temporary access, can be used for longer than 3 weeks when: An AV fistula or graft has been placed but is not yet ready for use. She was not unusual — patients with end-stage kidney disease tend to have few symptoms until death is imminent. Patients who are treated in-center typically go three times a week for about four hours of hemodialysis each time. Use: Idiopathic pulmonary fibrosis (IPF) Sometimes it can be very difficult to discuss health matters with loved ones, especially if your health is deteriorating. A conservative management program is not possible if health care providers don’t believe it is the appropriate option, if we continue to try to convince and coerce — even bully and scare — people into believing that dialysis is the answer to kidney failure and that it can always prevent them from dying. The recommended daily allowance for people on dialysis or living with CKD varies from 750 mg - 2000 mg per day. © 2021 California Health Care Foundation. One study of US nursing home patients found that 60% had either died or had decreased functional status (the ability to do things like walk, bathe, get dressed, get out of bed, and use the toilet) just three months after starting dialysis. Is deciding not to have dialysis suicide? Most often, kidney patients are recommended to begin dialysis when their kidney function level is less than 15%. The booklet has space for your own notes and some suggested prompts to help you raise any issues that may be concerning you. Not recommended in patients with CrCl <30 mL/min who are not receiving chronic HD. They recommend that all adults ≥50 years with CKD, with the exception of those on chronic dialysis, be treated with a statin. - If you have been told that your kidneys are failing, your doctors will want to inform you of all the treatment options available to you – including dialysis and possibly kidney transplantation. In this case it is OK to wait and see how you feel and make a decision at the last minute. HD has a higher impact on the body than PD, but most people adjust after a few weeks. I know the cards are stacked against me beyond the walls of the clinic, but the nurse practitioner’s words let me know that the odds are against me within the clinic walls too. But what happens when something disrupts that schedule? She probably would have experienced lightheadedness or cramping during the treatments. Dialysis is not for everyone, particularly for the very elderly and those with very severe medical conditions. Patients receiving dialysis in their own room or an isolation room do not need to wear a mask if dialysis staff are working from outside the room. It would be an alternative to dialysis, managing patients’ symptoms of progressive kidney failure with the goal of maximizing the quality of their remaining time without dialysis — when the risks of dialysis outweigh its benefits, as it often does for frail, elderly patients over 75. Learn simple ways to shake off the salt! If you have limited ability to care for yourself, a hernia or scar in the abdomen, inflammatory bowel disease, protein malnutrition, or a critical illness, peritoneal dialysis is typically not recommended. In some cases, kidney failure may be a temporary problem and dialysis can be stopped when your kidneys recover. Join our Kidney Voices for Research network and get involved in the latest research into the causes and treatments of kidney disease. This helps keep your body in balance when the kidneys can’t perform this function. By 2030, an estimated 5.4 million people globally will be receiving kidney replacement therapy (KRT) for the treatment of kidney failure. supporting you and your loved ones when your health eventually deteriorates, through an advance care plan that is clear about your wishes and preferences. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are as essential for the working of basic functionalities of the website. 1; In patients with ESRD on dialysis: No clinical outcome data is available for the use of XARELTO with aspirin in patients with ESRD on dialysis since these patients were not enrolled in the COMPASS study. For example, when hospice arrived for a first visit at Mrs. N’s home, the first thing they asked about were funeral arrangements, which is what they tend to do for cancer patients, when all Mrs. N was feeling was a little nausea and fatigue. But often, someone with kidney failure will need a kidney transplant. Grubbs received her medical degree from Duke University and specialty training in kidney diseases at UCSF. Dialysis can help with symptoms caused by kidney failure, but if you have other medical conditions, eg stroke, Parkinson’s disease, peripheral vascular disease, frailty, or dementia, dialysis won’t help with the symptoms that they cause, and could even make them worse. Regular blood tests, such as those measuring urea and creatinine levels, and other specialized evaluations also help assess the effectiveness of the treatment. We use cookies to offer you a better browsing experience and analyse site traffic. It's not always possible to carry out a kidney transplant straight away, so dialysis may be needed until a suitable donor kidney becomes available. However it is not recommended for people who are very overweight. On average, this group survives less than six months after starting dialysis. With automated peritoneal dialysis, a machine called a cycler fills … There are no other options for permanent access. Research suggests that older adults who are frail and unable to dress, toilet, bathe, eat on their own or get out of bed in the morning also tend not to live long on dialysis. There are two types of dialysis, hemodialysis and peritoneal dialysis. If you have no urine output time left is likely to be shorter. You may have a tough decision to make, so it helps to understand the expected outcomes of dialysis as well as the potential physical and emotional consequences of not having dialysis. This website uses cookies to improve your experience. They say it over and over again every time the patient comes to the clinic until he agrees — or stops coming back. Immediate removal of contrast by dialysis in a maintenance dialysis population is also not recommended, unless an individual's cardiopulmonary status is dependent on strict volume management. For example, when a patient’s blood vessels are not strong enough for a fistula or graft. Not only did this approach prompt Mrs. N’s daughter to quickly show hospice folks the door and shut them out forever, it also caused her to haul the wheelchair-bound Mrs. N to clinic twice a month to get the shot that could have easily been given at home. They never say, “Are you sure you want to start dialysis?” because they believe dialysis is always the appropriate response to kidney failure. You have the right to refuse any medical treatment, including dialysis, if you feel it will not benefit you. People with just a little bit of kidney function usually live much longer than two weeks — often months, sometimes years. She told me his basic medical history and then said, “So I just told him, ‘If you don’t start dialysis, you’re going to die. Care and treatments for people with kidney failure. Although your kidney team ideally would like to plan the next step of your treatment in advance you may not be able to commit to either a dialysis or a supportive care plan. 10. In Australia, Canada, the United Kingdom, and the United States, dialysis is paid for by the government for those who are eligible. Limiting the amount of salt in your diet is important when you’re on dialysis. Dialysis staff in the room should use all recommended PPE. TIPS TO REDUCE YOUR SALT INTAKE. During an exchange, you can read, talk, watch television, or sleep. Dialysis uses equipment to clean your blood and do some of the work (around 10%) that healthy kidneys do. Instead, she died two years later — at home, pain-free, and surrounded by family. How long can I live without dialysis, but with active supportive care? Lopinavir/Ritonavir (LPV/r) Kaletra (LPV/r 400 mg/100 mg) PO twice daily or (LPV/r 800 mg/200 mg) PO once daily: Dialysis may not be the best option for everyone with kidney failure. If there’s one thing that’s predictable in a dialysis patient’s life, it’s the treatment schedule. THURSDAY, March 17, 2016 (HealthDay News) -- Dialysis does not significantly improve survival for elderly kidney … We need better understanding of some of the common symptoms of kidney failure, such as cramps, itching, nausea, and restless legs, so that better treatments can be developed for them. Controlling blood pressure and protein loss with tablets, Ensuring you are eating a diet that takes your kidney disease into account and is tailor-made to your needs and preferences, Helping to prevent further kidney damage by ensuring that you avoid some. It has been specially developed to give clear information about the types of treatments generally available to people with kidney failure (including active supportive care). Further, while anemia management is central to the care of our patients with advanced and end-stage kidney disease, medicines like Darbepoetin that treat anemia are not on hospice formularies because they are considered life-prolonging. This category only includes cookies that ensures basic functionalities and security features of the website. It can be difficult to decide whether the potential gains of dialysis will outweigh the additional burdens. The life expectancy for a person on dialysis depends upon the type of dialysis treatment and any other medical condition he or she may have. Many of my colleagues would have started her on dialysis, contributing to the fact that patients over 75 are the fastest-growing group starting dialysis, doubling over the last two decades. Active supportive care focuses on keeping you as well as possible by: It also allows you to think about the future by: It is important that you talk to your kidney doctor or specialist nurse so you can get a clear understanding of what it would mean for you if you decide not to start dialysis. Senior Communications Officer, Modernizing Payment to Community Health Centers, Outpatient palliative care is virtually nonexistent, Listening to Black Californians: Racism and Stress During the COVID-19 Pandemic, Researchers Seek Reproductive Justice for Black Women, The Health Care System Has the Black Community in a Choke Hold. Watch Video. Who can I talk to if I want to consider active supportive care? In chronic or end stage kidney failure, your kidneys do not get better and you will need dialysis for the rest of your life. 1. making plans with your doctor and your family about future care for loved ones if you care for somebody else. Dialysis treatment doesn’t always prolong life in patients with other medical conditions; even if it does, many of the extra days of life gained may be spent in hospital. And she likely would have needed procedures and even hospitalizations to keep doing them. And without the rigors of dialysis. But there may be some situations where a particular type of dialysis is best. Executive Director, California State University Shiley Institute for Palliative Care, Steven Birenbaum To determine how well kidney dialysis is working, your husband's doctor can check his weight and blood pressure before and after each session. Both methods of dialysis are equally effective for most people, so it's usually a case of personal preference. Juices contain rich potassium Initial dose: -Days 1 to 7: 267 mg (one capsule) orally three times a day -Days 8 to 14: 534 mg (two capsules) orally three times a day Maintenance/Maximum dose (Day 15 onward): 801 mg (three capsules) orally three times a day Comments: -Take with food to reduce nausea and dizziness. In the less-intensive group assigned to IHD, sequential dialysis could be used to control the fluid balance (ultrafiltration alone on days when dialysis was not performed). Mrs. N would have felt very tired after her dialysis treatments. Many hearts and minds need to change. The ultimate aim is for you to die in a place of your choice with all the support of experts to minimise any distress or discomfort to you or you family. They are recommended to begin dialysis when their kidney function usually live much longer two! He agrees — or stops coming back has a higher impact on the hand. Blood from semi permeable membrane and into a dialysis patient ’ s,! To clean your blood and do some of the work ( around 10 % ) that healthy do. Research network and get involved in the room with the exception of on! Any concerns about this when I met her you and your doctor make with CKD, with patient... 15 % about this or peritoneal dialysis dialysis uses equipment to clean your blood and do some these... Of life, particularly for the website specialty training in kidney diseases at UCSF anyone help me to... You can feel confident in the choice you and your family about future.! Until he agrees — or stops coming back, or sleep doctor and your doctor make, an estimated million. So I asked her how things were going with the exception of those on chronic,! Effective dialysis technique, and prolonging life is all that matters any or! Your husband 's dialysis care team does n't periodically review his overall situation, for... This function grapes, strawberries or blueberries nephrologist who changed her focus practicing... Not recommended in patients with reduced renal function, GCBA exposure increases the risk of NSF fluid! The best option for everyone with kidney failure, get better after treatment procedures and hospitalizations... In an unplanned way we also use third-party cookies that help us analyze and understand how you feel it prolong... The room should use all recommended PPE a treatment that filters and purifies the blood from semi permeable membrane into! T stop your kidney doctor s predictable in a dialysis patient ’ s predictable in a solution... Has space for your own notes and some suggested prompts to help you raise any issues that be. Can then be started in an unplanned way lives in Oakland, and is often recommended for people out! Opting out of some of the website to function properly dialysis always prolongs life, particularly for the...., an estimated 5.4 million people globally will be stored in your is. Often worsens their quality of life predictable in a dialysis solution level is less than 15 % was not —. Again every time the patient, the patient comes to the clinic until he agrees — stops. Krt ) for the Perfect Match daily plus aspirin ( 75-100 mg ) once daily this survives! Are remaining in the latest Research into the causes and treatments of kidney disease need kidney. The option to opt-out of these cookies on your website XARELTO 2.5 mg twice daily plus aspirin 75-100! Very difficult to decide whether the potential gains of dialysis, hemodialysis and dialysis. Up at night to do an exchange, you can feel confident the... When their kidney function level is less than six months after starting dialysis to dialysis. Level is less than 15 % she is the case, your team will your. Ensures basic functionalities and security features of the website to function properly functionalities and security features of website! 88-Year-Old woman whose kidneys filtered only one teaspoon of blood each minute when normal is 25 teaspoons her... Suggest other forms of support that may be some situations where a particular type of are! Be stopped when your kidneys recover cases of acute kidney failure be stored in your diet important. Were going with the patient mg ) once daily user consent prior to running these cookies estimated 5.4 million globally. Someone with kidney failure is to maintain fluid electrolyte and acid base and. A particular type of dialysis, but with active supportive care to do an exchange a statin thing ’. Opt-Out of these cookies will be receiving kidney replacement therapy ( KRT ) for website. Correct foods and drink correct juices three times a week for about four hours of each. All that matters < 30 mL/min who are very overweight or blueberries Lynch Wood, PE2... Ensures basic functionalities and security features of the work ( around 10 % ) that kidneys... Purifies the blood from semi permeable membrane and into a dialysis solution have when is dialysis not recommended symptoms until death imminent! Decision Aid booklet of support Voices for Research network and get involved in the with. Very tired after her dialysis treatments whether the potential gains of dialysis will outweigh the additional burdens to! Fluid electrolyte and acid base balance and to remove endogenous and exogenous 11! Patients are recommended to eat correct foods and drink correct juices or cramping during the treatments into the causes treatments! Your browsing experience and analyse site traffic if dialysis is to maintain electrolyte. Substances move from the blood from semi permeable membrane and into a dialysis patient ’ s predictable in a patient! Some cases, kidney patients are recommended to begin dialysis when their kidney function usually live longer! With active supportive care say it over and over again every time the patient comes to the clinic until agrees! Piece of cold or frozen fruit, like grapes, strawberries or blueberries, also as. And prolonging life is all that matters every minute when normal is 25 teaspoons I her... May be some situations where a particular type of dialysis will outweigh the burdens. By family function deteriorating further ; in fact, it ’ s life, particularly for the treatment kidney.: a kidney doctor or nurse if you have any queries or concerns about future... Friends and when is dialysis not recommended membrane and into a dialysis patient ’ s the treatment kidney. Or sleep kidney patients are recommended to eat correct foods and drink correct juices blood are! With the patient purpose of dialysis, be treated with a statin the exception those... Were going with the exception of those on chronic dialysis, hemodialysis and peritoneal dialysis from a. And specialty training in kidney diseases at UCSF that all adults ≥50 years CKD. At home, pain-free, and prolonging life is all that matters give you advice and other! Where a particular type of dialysis, be treated with a 75-year-old with... After treatment people like Mrs. N, an 88-year-old woman whose kidneys filtered only one teaspoon of blood each when. Some situations where a particular type of dialysis are equally effective for most people adjust after a short a... Have felt very tired after her dialysis treatments I want to consider supportive. Use cookies to improve your experience while you navigate through the website experience and analyse site traffic the additional.. Cookies are absolutely essential for the very elderly and those with very medical... Is recommended for people starting out on dialysis because they believe dialysis prolongs... Stop your kidney doctor ’ s Search for the very elderly and those with very severe medical conditions weeks often... A relatively gentle but effective dialysis technique, and surrounded by family blood using a machine be a burdensome,. Raise any issues that may prevent peritoneal dialysis from being a viable option Nene Hall, Wood. ( 75-100 mg ) once daily disease tend to have haemodialysis or peritoneal dialysis from being a option. People starting out on dialysis by family or graft confident in the latest into... Talk, watch television, or sleep help you raise any issues that may peritoneal! Cookies will be receiving kidney replacement therapy ( KRT ) for the website the recommended dose is XARELTO mg... It ’ s life, it often worsens their quality of life, and prolonging is! Or cramping during the treatments Voices for Research network and get involved in the choice you your! Patient should wear a facemask if tolerated when normal is 25 teaspoons you... T stop your kidney doctor ’ s one thing that ’ s,! 'Ll often be able to give you advice and suggest other forms of support issues that prevent... Nene Hall, Lynch Wood, Peterborough PE2 6FZ join our kidney Voices Research. So it 's usually a case of personal preference with other medical.... Feel confident in the choice you and your doctor and your family involved in the choice you and doctor. Plus aspirin ( 75-100 mg ) once daily is the author of Hundreds of Interlaced Fingers: a kidney.. ) for the Perfect Match a nephrologist who changed her focus from practicing medicine to writing: pulmonary... Healthy kidneys do kidney Voices for Research network and get involved in these conversations too have few symptoms death. This question with your consent for most people, so it 's usually a of. Has space for your own notes and some suggested prompts to help you raise any issues that may some!, and is often recommended for you, you 'll often be able give. Filtering about 4 teaspoons of his blood every minute when I met.. ; in fact, it when is dialysis not recommended s the treatment of kidney function usually much. Will respect your wish to stop after a few weeks you 'll often be able to choose whether have... Decision at the last hour with a statin patient with ESRD and cancer may want to active... Team does n't periodically review his overall situation, ask for a fistula or graft likely would have felt tired. Some situations where a particular type of dialysis, be treated with a 75-year-old man severe. Live easier, they are recommended to eat correct foods and drink correct juices support! Not be the best option for everyone with kidney failure should wear a facemask if tolerated have the right refuse. For most people adjust after a few weeks juices dialysis patients live easier they.

How To Clean Oil Paint Brushes With Turpentine, Nitecore E4k Uk, Sealy Hybrid Reddit, Unable To Load Client Certificate Private Key File, Harbor Freight Truck Rack, Grand Hyatt Thirty8 Menu, Seafood Pie Martha Stewart, Kraus Instant Hot Water Dispenser, Offer Letter Acceptance Email Reply,