What are the psychologic consequences of long-term dialysis?

Dialysis may have a major impact on a patient’s psychosocial status. Some patients have a gradual decline in quality of life, particularly as medical complications become more severe. This can lead to depression and an increased risk of suicide. Other patients experience an excellent quality of life and are highly rehabilitated and productive. What distinguishes these two patient groups remains uncertain. Close attention to psychosocial adaptation, with psychiatric intervention and counseling when needed, can help patients to optimize the quality of their lives while on dialysis.

Is it possible to predict how a patient will react to maintenance hemodialysis?

Little work has been done to help healthcare professionals predict how patients will react to the multiple changes and stresses associated with life on dialysis. Most studies have involved small numbers of patients and showed little agreement regarding predictive parameters. An individual’s method of coping with past life stresses remains the best single indicator of his or her adaptability to daily life with dialysis. Frustration tolerance, aggression, denial of the sick role, and obsessive-compulsive characteristics are personality traits that can be evaluated and used to help predict a patient’s potential adjustment to dialysis.

An evaluation of the patient’s coping methods is conducted in part by a mental health professional (usually a clinical social worker) on the dialysis treatment team. An in-depth psychosocial evaluation that includes interviews with both the patient and the family is conducted by the social worker at the initiation of chronic dialysis treatment. Based on this evaluation, a treatment plan is formulated to include psychosocial counseling and community resource referrals that can enhance the patient’s ability to cope. Often the social worker can provide support and reassurance to patient and family as well as help alleviate pressing resource needs by assisting with financial and insurance problems.

What stages of adjustment to dialysis might a patient with chronic kidney disease experience?

When the onset of CKD is gradual, the patient has time to adjust to the idea of dialysis and to make well-informed treatment choices. The initial response to dialysis itself can be one of relief, especially if the patient has been feeling ill for a period of time. Unfortunately, some patients delay beginning dialysis until they are quite ill and then may require the initiation of dialysis on an emergency, hospitalized basis.

When the onset of CKD is sudden, there can be an acute crisis phase of adjustment, often marked by feelings of shock, disbelief, desperation, and depression. In such cases, a crisis intervention approach by a trained mental health professional is indicated. Three stages of patient adjustment to dialysis have been identified:

These periods of adjustment are presented as general guidelines only. Not all researchers and practitioners agree about this sequence of phases. There is not always a linear progression from one stage to another, and for individual patients the various stages may be much briefer or much longer than indicated above. Further, patients may shift back and forth from stage to stage for a variety of reasons, including medical complications.

How can the quality of life of a patient on dialysis be evaluated?

Quality of life is a phrase that is sometimes used interchangeably with such terms as life satisfaction, well-being, and morale. Usually, quality of life is defined as encompassing major areas of functioning in the physical, psychological, and social realms. Further, feelings about this issue are relative perceptions for each individual, and any attempt to evaluate quality of life must take into account the significance of these highly subjective perceptions. An intolerable situation for one patient may not be intolerable for another.

Several instruments that measure quality of life for research purposes may be used for clinical assessment as well. In addition to using formal measures, dialysis personnel should provide patients with opportunities to talk about their own feelings and perceptions regarding their quality of life.

What can be done to enhance the quality of life for dialysis patients and their families?

Evaluation and planning for psychosocial intervention should begin before the patient actually needs dialysis. Patients and their families should be educated about dialysis and be encouraged to participate actively in deciding various aspects of the treatment program, including the type of dialysis and the need for access placement. Evaluation of the type of dialysis to be used for a patient should include an assessment of the challenges he or she is facing, as well as personal, family, work, and social considerations. It is essential for staff to identify individuals who are at great risk for psychosocial dysfunction because early introduction of vocational and psychotherapeutic counseling (for the patient or family) can increase the patient’s rehabilitation potential and improve his or her quality of life.

After a patient has begun dialysis, the dialysis staff needs to institute interventions to maximize the positive effects and minimize the negative effects of dialysis on the patient’s quality of life. Such interventions might include counseling by the dialysis social worker or other mental health professional that is familiar with the dynamics of CKD and the dialysis process.

What are common sources of stress for dialysis patients?

Patients on maintenance dialysis are confronted with severe limitations and demands on themselves and their families. They must contend with changes in family relationships, such as role reversal and deteriorating sexual responsiveness, and with accompanying feelings of guilt, depression, and loss. It is suggested that 20% to 30% of all maintenance dialysis patients have significant depressive symptoms (Chilcot et al., 2010). Depression has been found to have profound effects on the overall health and well-being of patients with a chronic disease. The threat of reduced job responsibility or unemployment can contribute to feelings of worthlessness and loss of self-esteem. Many patients experience conflict between the need to be dependent on a machine and on other people and the desire to remain independent. They may feel that they have relinquished control of their lives to the dialysis team. Underlying many of these feelings is the basic fear of dying. The patient’s dependence on the dialysis machine can be a constant reminder that he or she has been rescued from death.

How can the dialysis team assist patients and families in coping when dialysis becomes necessary?

Dialysis patients and family members who regard renal failure and the need for dialysis as a loss may grieve over that loss. Dialysis personnel should be familiar with the issues of grief and the grieving process and be prepared to provide appropriate intervention or call upon a resource person, such as a psychiatric nurse, social worker, psychologist, or psychiatrist, as needed. If members of the dialysis team are able to recognize periods of exceptional stress and use appropriate crisis intervention approaches, they can help patients cope with such periods and prevent major adjustment problems.

Patients who are unable to accept the restrictions imposed upon them by dialysis may become depressed and unable or unwilling to adhere to their dialysis regimens. When this occurs, the diminished quality of life and increased potential for death should be addressed by prompt recognition and social work or psychotherapeutic intervention.

What are some psychological reactions and common coping mechanisms of patients on maintenance dialysis?

Anxiety is the initial reaction for most patients and families faced with the prospect of life on dialysis. Such anxiety is entirely normal, and the dialysis staff needs to reassure patients that this is the case.

Depression may occur early in the treatment process. Again, this is a rational reaction to the prospect of a limited and risky life that will require totally different objectives than would have been planned otherwise.

Hostility and anger are frequent reactions of patients on dialysis. Hostility toward dialysis personnel and the medical regimen is actually a reaction to the limitations imposed by the disease, but this anger is displaced to the treatment staff and procedure.

A difference of opinion exists as to the role that the denial mechanism plays in patients who have become stabilized on dialysis. To staff involved in the primary care of these patients, denial seems to be a common defense that allows patients to cope with the realities of the situation while regarding it as not a part of their real selves. Denial used in this way can be very useful for the patient because it shuts out negative aspects of the illness. However, denial can be carried to extremes, subverting medical management, and the result can be disastrous.