resistance to home dialysis - The International Journal of Psychiatry

RESISTANCE T O HOME DIALYSIS
A. Kaplan De-Nour, M.D. and J. W. Czaczkes, M.D.*
Hadassah University Hospital
Jerusalem, Israel
ABSTRACT-This report on the difficulties of training patients for home dialysis
is based on two years of experience with eight patients. In that period only one patient has gone on home dialysis; another is on his way, and the other six patients
are still in various stages of resistance to home dialysis.
Clinical psychiatric observations carried out during these two years helped to
identify five factors that influence the patient’s and the family’s attitudes to home
dialysis. In the present report two of these factors were briefly described: the financial situation and what we called the “set-up” as well as the “normal” apprehension and fear of dialysis. More attention was given to the other three factors: the
attitude of the medical team, which in our unit was strongly anti-home dialysis and
was attributed to overprotectiveness, possessiveness and injury to the professional
image; the personality of the patient as it influenced his attitude to home dialysis
and especially the patient’s dependency needs; and the patient’s family emphasizing the family’s aggression and methods of handling it.
Towards the end of the report some suggestions for avoiding the extreme resistance to home dialysis were brought up.
INTRODUCTION
IN a psychiatric study of patients in the chronic hemodialysis unit of the
Hadassah University Hospital started over three years ago, we have gathered
the impression that there are five sources of stress for these patients: (a)
dependency on the machines and medical staff; ( b ) aggression resulting
from this dependency; (c) repeated frustrations caused by the strict medical
regime; ( d ) threat of death; and ( e ) changes in body image due to lack of
urination (Kaplan De-Nour et al., 1968, 1969, 1970). This analysis of the
stresses of chronic hemodialysis led us to the conclusion that home dialysis
might be less stressful, especially concerning the first three mentioned
stresses. I n home dialysis there is very little dependency on the medical
staff and the feeling of dependency on the machines would be less when
patients learned to handle and master their machines. It was expected that
lThis work was supported by US. Department of Health, Education and Welfare, Public
Health Service Grant CD-IS-7.
2From the Department of Psychiatry and the Chronic Renal Disease Unit, Hadassah University Hospital and Hebrew University-Hadassah Medical School, Jerusalem, Israel.
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doi: 10.2190/9JNM-9KH5-U837-2M8A
http://baywood.com
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Psychiatry In Medicine
as dependency decreased, aggression would also decrease, and verbal expression of aggression seemed more possible in a home setting than in a hospital
unit. In home dialysis the medical regime could be less strict, offering the
patient some freedom in changing the day of dialysis and thus compensating
for some dietary irregularities.
Furthermore, the effort to build up a home dialysis program was based
on the conclusion that, in the present state of the art, an individual who is
medically and psychologically suitable for dialysis has a better long-term
prognosis on dialysis than after transplantation.
This impression that home dialysis might be less stressful to many patients was supported by reports from a number of units in Great Britian
and the United States stating that home dialysis is not only feasible and
less expensive but also medically and psychologically better for the patient
(Baillod et al., 1965, 1966, 1967; Curtis et al., 1965; Hilton, et al.,
1967; Barnett et al., 1966; Eschbach et al., 1966, 1967; Hampers et al., 1965,
1966; Kaye et al., 1968; Merrill et al., 1964; Rae et al., 1967, 1968). Though
few recent reports have described the stresses of home dialysis, especially on
the family (Shambaugh et al., 1967, 1969), we have come around to Scribner's
opinion (1967) that "the future of chronic dialysis lies in the home."
We have therefore started to discuss home dialysis with nearly all our
patients, making it a condition for acceptance to some patients, as well as
trying to start training patients for home dialysis. We have soon realized,
however, that transferring patients to home dialysis is not as simple and
easy as described in the above mentioned reports. Some patients and/or
families refuse even to start training, while others take much longer in
training than the two to three months reported in the literature. A recent
report (Smith et al., 1969) on the problems and frustrations of home
dialysis encouraged us to summarize the difficulties we have encountered
and what we believe have been the sources of resistance to home dialysis.
TRAINING FOR HOME DIALYSIS
In the last three years, fifteen patients have been on chronic hemodialysis
in our unit. Seven patients were transplanted during the first two years.
Home dialysis was discussed with one of the two patients successfully returned to dialysis after rejection of the transplant, as well as with seven of
the eight patients who had not been transplanted. Altogether, therefore,
home dialysis was discussed, suggested or made a condition with eight patients. Table 1 summarizes the background of these eight patients.
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Resistance to Home Dialysis
TABLE 1
Background of Patients
Patient
Number
Sex
Age
F
F
F
M
F
M
M
M
32
33
42
23
39
42
33
61
Marital Status
and Numlier
of <:hil(lren
+
ILI
2
M+3
M+4
M
M
9
M+4
M+3
M+2
+
Education
Occupation
Spouse’s
Occupation
High school
Elementary
High school
University
None
Elementary
Elementary
High school
Housewife
Housewife
Housewife
Student
Housewife
Bus driver
Contractor
Farmer
Accountant
Clerk
Shop owner
Student
Teacher
Houscw i fe
-1‘cach cr
Housewife
T h e social economic condition of two of the patients (Patients 2 and 5)
was poor also before dialysis, and another patient (Patient 7) was in bad
financial circumstances as he had to change his place of work. T h e other
five patients belonged to what is regarded as middle-class in Israel.
TAIILE 2
History in IJnit
Patient
Number
1
8
Attitude to
home dialysis
Beginning of dialysis
Homc dialysis
March 1966 (March
1967-Nov. 1967 transplantation)
Suggested beginning
of 1968
R e f LI scd
May 1966
Suggested beginning
of 1969
Still training
December 1966
“Condition” for
acceptance
Refusal to train
December 1967
Suggested beginning
of 1968
Refused by parents:
fully trained with wife
(married Sept. 1969)
July 1968
“Condition” for
acceptance
On home dialysis from
Dec. 1968
April 1969
“Condition” for
acceptance
Slow training-spouse
refuses training
April 1969
Suggested before
acceptance
Training though at
present cannot afford
installation
June 1963
“Condition” for
acceptance
Donated money to
build a unit in his
home town
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T h e patients have been on chronic hemodialysis for varying lengths of
time. Table 2 summarizes their history in the unit.
One patient (Patient 1) refuses to consider it, saying that she “is not
to be blamed and punished for being ill,” adding that “doing home dialysis
would mean living for dialysis instead of doing dialysis in order to continue living” and at times declaring that she “likes dependency and would
like many physicians and nurses to be around when she is on dialysis.”
Her husband also refuses to consider home dialysis, saying “it will drive him
and the kids crazy” and threatens divorce if home dialysis is “forced.”
Another patient (Patient 2) does not refuse actively but she and her husband have been extensively “training” for home dialysis for nearly a year
and hardly know anything. When the patient or her husband have to
come for their “lesson” they usually feel ill. T h e husband complains of
low back pain that prevents him from taking care of the machine. H e has
also rediscovered minimal dermatitis which he has had for years, attributes
it to the formalin solution and therefore says that he cannot continue to
prepare the machine. H e also scares all the other patients by stating that
they too will have all sorts of skin troubles.
T h e third patient (Patient 7) seems to be eager to go on home dialysis,
picks u p a lot of knowledge though not officially in training, but at present
he cannot afford it financially. T h e last patient of this group (Patient 4)
seems to be the only one who will go on home dialysis in the near future.
When he started dialysis his parents refused home dialysis, saying that they
“would never learn to handle the machine and were sure to kill their only
son” and offered a kidney for transplantation. Later he trained eagerly with
his wife and will soon be transferred home with a machine which the unit
“lends” him.
Four other patients who had no financial problems (two were well off
and the other two were helped by their communities) were accepted for
dialysis with the understanding that they go on home dialysis. Of these
four patients, one (Patient 5) went on home dialysis after six months of
training. Another (Patient 8) donated money to a hospital in his home
town to build a unit, and when this is ready he will receive treatment
there. T h e family of the third patient (Patient 3) says “it is impossible”
and admits that they lied when they agreed to home dialysis. This family
brought u p mostly financial reasons. Lately, however, when a sort of selfservice without expense is being considered, the husband refuses even to
discuss it, intends “to complain to the director of the hospital and later,
perhaps, also to the municipality and parliament.”
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Discussion of a Specific Case
T h e fourth patient (Patient 6) and his wife also say it is impossible
although he was given a new flat, the machine was bought for him, and
running expenses were to be covered by his community. This patient is a
forty-two-year-old bus driver, married with four children, who knew of
his kidney disease (polycystic kidney) for more than ten years. He had also
known for many years that his disease is familial. An older brother antl
two older sisters hatl died ot renal failure at around the age of forty. Of
the two remaining younger brothers, one is known to have a polycystic
kidney and the other reluses to undergo examination. T h e patient’s wife
has known about his disease for more than five years.
T h e patient hatl known for more than two years that he would eventually go on home dialysis and was very eager to start it. T h e last sister
to die was to h a ~ egone on dialysis in 1967. At that time war broke out
in the country. T h e unit (not ours) which was to have taken her on could
not because of the military situation and she died in June, 1967. We believed that this also explained the patient’s ieadiness and eagerness to go
on home dialysis-he
wanted his own machine safe and sound in his
home. He had discussed all this with his cooperative who bought him a new
apartment (as he hatl a small two-room apartment in a slum area) and paid
the money for his machine. T h e patient’s wife took an active antl eager
part in all these discussions and arrangements. Dialysis was started in April,
1969, and a month or two later they moved into their new apaitment. O u r
plan was then to start his training tor home dialysis. T h e patient, however,
was repeatedly late for training and when we “got tough” he started to
come on time but was either too weak or just could not learn how to clean
and assemble his machine (I.Q. tested before dialysis 110).
At this stage the patient still professed that he wanted to go on home
dialysis. T h e wife, who had visited thc unit a number of times before her
husband started dialysis, could not mine because she “could not stand the
sight of blood in the tubes.” She complained that she was too nervous and
that she could not do home dialysis because she “sleeps too soundly antl
will not hear the alarms.” Discussing all this with the wife elicited a description of fifteen years of marriage and misery. She never got any attention from her husband; she was abused and not accepted by his family;
she did everything for the children (cooking a special meal for each of
them every day), a w l they abused her and did not listen to her. When we
started visiting the home in order to decide on the necessary installations
she brought in her senile and hated mother to live with her. During the
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Psychiatry I n Medicine
sessions she described at length her feelings of deprivation and thereby explained her disinclination to work for her husband. She refused, however,
to connect these kelings with her conviction that she “would kill her
husband on dialysis.” When we wanted to move the machine to the house
she went away to a never-visited sister and later told her husband to
choose, “Either I stay or the machine but not both of us.”
I n the meantime the patient reached the conclusion that “doing dialysis
without an attending physician is a criminal lack of responsibility” and
that doing home dialysis in the presence of the children “would cause them
irreversible psychological damage.” (Although at times the parents force
their elder daughter to come and visit her father on dialysis so that
“she would see how he suffers and then behave better at home.”)
Many more items from this struggle could be presented. T h e end of it
was that we gave up. T h e patient is still officially on training (for the selfservice unit that is to be opened) and still has not learned how to operate
the machine. T h e wile is officially off training, and she is the only wife
who comes to visit on each dialysis with all sorts of presents.
Comment
T o sum u p our results of transfcrring patients to home dialysis, in three
years one out of eight patients went home and another one will probably
go home soon. Table 3 summarizes what we believe to have been the main
overt obstacles.
TABLE 3
Main Overt Obstacles
Patient
Number
6
7
8
Patient’s attitude
Spouse’s attitude
Refusal
Extreme refusal
Passive resistance
Passive resistance
Passive resistance
Extreme refusal
Eager
Eager
Went on home dialysis
after six months’ training
Passive resistance
Extreme refusal
Eager
Ready to cooperate
Refusal
Refusal
Financial
problem
Not considered
Not considered
None
Many
None
Many
None
SOURCES OF RESISTANCE
We believe that five factors influencing a patient’s readiness or resistance
to go on home dialysis are:
Resistance to Home Dialysis
213
1. T h e “set-up,’’ by which we mean the initial, universal and normal
reactions of the patient and his spouse to a home dialysis program, and
the objective effects of the dialysis unit (or training unit) on these
reactions.
2. T h e attitudes of the medical team.
3. T h e patient’s personality.
4. T h e attitude of the spouse.
5. T h e financial set-up.
For few patients, only one or two of these factors are decisive, while the
others are of secondary o r little influence. With most of the patients, however, most o r all factors are of great influence. We would like to describe
in some detail each of these five factors.
T h e “Set-zip”
Anxiety and fear are the initial reactions of all patients to dialysis. They
include fear of pain, fear of the unknown, anxiety about death and about
possible changes in the way of life. Most of these fears are shared to varying degrees by the family. T h e fear of home dialysis is even greater. Learning a new “profession” and taking responsibility for the multitude of medical and technical details. T h e actual technical burden, the preparation for
and the cleaning after each dialysis, takes about an hour a n d one-half, two
to three times a wcek. During dialysis itself the family has to be at home
b u t not necessarily awake. I n our experience the alarms with the machine
used so far (MAKS 900 Home Dialysis System, Bio/Systems, Inc.) are very
few so that technically the patient and his family could sleep throughout
dialysis. At all times the family (or the patient) can reach by phone a
special physician, who is to be in charge of home dialysis, or one of our
technicians, who is on duty every day around-the-clock. Considering the
small size of the town this means that a “professional” can reach the
patient’s home if a n d when necessary in less than fifteen minutes. T h e
actual work and responsibility of preparation and dialysis rests, however,
with the patient and his family. T h e overall medical care, including the
periodic blood tests, is handled by the hospital unit.
O u r whole culture teaches us that the “good” patient and his family are
supposed to follow the physician’s orders to the letter, preferably without
inquiring into the reasons for these orders. Here, the patient and his
family are suddenly expected to take on the role of the medical team and
they naturally react with fear and apprehension. Training patients for
home dialysis in a regular treating unit seems to increase these tears; they
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Psychiatry I n Medicine
observe that the dialysis is performed by a comparatively large and highly
skilled medical team. T h e meticulous care given to all details and any
minor complication increases their feelings of inadequacy and inability
to cope with a complicated situation. T h e impact of a separate training
unit, however, seems to be different as the patient and his family from
the very beginning are partners in the treatment and each new skill acquired
by them enhances their feeling of mastering the situation.
T h e Attitudes of the Medical T e a m
T h e physicians of our unit have gradually reached the opinion that home
dialysis is not only necessary but also feasible. Most of them, however,
continue to doubt whether a patient’s medical condition on home dialysis
can be as good as on hospital dialysis.
We have gradually observed that the attitude of the rest of the medical
team is even more anti-home dialysis. Patients and families are repeatedly
excused from training because “the patient was weak, the spouse was busy,
the patient’s child ran a temperature, other patients require more attention, and the team is overworked.” They have often complained that the
patient, though of normal or high intelligence on psychological tests, is
too dumb to learn to assemble his “kidney.” T h e nurses objected to working with the automatic machine, complaining that it is too complicated
and that they are too busy to learn it. I n the weekly staff conferences we
have started to point out to the team that their behavior indicates their
objection to home dialysis.
Discussing this acting-out brought into the open the attitude of the
medical team. They have started to blame the chief of the unit for lack
of understanding, lack of consideration and even of cruelty to the patients.
These discussions (or fights) often end by the chief physician being told,
“I would like to see you going on home dialysis.” These extreme objections
to home dialysis are not based on reality and have therefore not been
influenced by arguments or facts; they discount or disbelieve reports from
other units that patients do well on home dialysis. They even do not
trust the good adjustment of our only patient on home dialysis. Though
this patient has been on home dialysis for nearly a year, some of them
daily expect a breakdown of the whole situation, while others explain it
away with the argument that “she is a special case.”
We doubt whether we have a n adequate explanation for the team’s attitude. I n a previous report (Kaplan De-Nour and Czaczkes, 1968) we have
described the overprotectiveness and the possessive attitude of our medical
Resistance to Home Dialysis
215
team. It would seem that these two attitudes form part of their resistance
to home dialysis. Appreciation of the psychological burden which home
dialysis imposes upon the families does not seem to play a role in this
resistance. I t has always been “the poor patient who has to go home” antl
not his family. Home dialysis is also a threat to the professional self-esteem
of the medical team. Here we take a complicated method of medical treatment and turn it over to a layman. A graduate nurse trains from three to
six months before she is considered a dialysis nurse, while we say that a
patient or his spouse can finish their training in two to three months.
Similar difficulties have been encountered in other fields of medicine (e.g.,
psychiatry) when treating responsibilities have been turned over to nonprofessionals.
We believe that these three factors (possessiveness, overprotectiveness
antl the threat to the professional self-image) offer at least somc explanation
of the medical team’s extreme anti-home dialysis attitude. Furthermore
we feel certain that, though the team does not discuss their attitude with
the patients, it is nonverbally communicated to the patients and increases
their fear, anxiety, and resistance to home dialysis.
We believe that this factor-the
attitude of the medical team-is
of
extreme importance in influencing the attitude of the patient and his
family. Furthermore we think it is the main source for the tliscrepanry between the (usually unpublished) reports from institutional units that “it
is impossible to convince patients to go on home dialysis” antl the encouraging reports, mostly from special training units. I t seems that, without any
deep psychological analysis, some centers have arrived at the following
solution: in a separate training unit there is a “natural” selection of the
medical team-the ambition of the physicians, nurses antl technicians who
work in such a unit is to train patients as efficiently as possible. We would
furthermore like to suggest that they have “special” pcrsonalities which
enable them to share the treatment with nonprofessionals.
The Pat ien 1’s Persona lit y
T h e third factor influencing a patient’s attitude to home dialysis is his
personality. A number of reports mention that emotional maturity and
psychological stability is required of patients planned for home dialysis
(Baillod et al., 1966; Hampers et al., 1965; Shaldon, 1968). Our impression
has been that one personality trait is of special importance, namely, the
patient’s dependency needs. As has been presented elsewhere (Kaplan DeNour and Czaczkes, 1969), our clinical impression, supported by findings
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Psychiatry I n Medicine
of psychological tests, is that patients with strong accepted dependency
needs prefer hospital dialysis and refuse to go on home dialysis. O n the
other hand, patients with strong needs to achieve independency (usually
because of strong rejection of dependency needs) do not want to stay on
hospital dialysis, train fast, take the responsibility for the dialysis and regard
their spouses as mere helpers (Patients 4 and 8).
A similar opinion that patients who are “independent by nature . . .
adjust particularly well to home dialysis” has already been mentioned by
Eschbach et al. (1967).
We believe that with patients belonging to one of these two groupsstrong dependency needs or strong rejection of dependency-their
personality will be the deciding factor whether they go on home dialysis or
not. Patients of the first group will not go on home dialysis even if all
other factors are favorable for home dialysis, while patients belonging to
the second group will eventually find their way to home dialysis, even if
that way is paved with many obstacles.
Most of the patients, however, do not belong to either extreme but fall
somewhere in between. With them it seems that the outcome does not
depend primarily on their personality. When other circumstances are
favorable for home dialysis (as with Patient 5) they will eventually go home
though the training might take a long time, and when other factors are
anti-home dialysis, their personality will not be “strong” enough to move
them home. We would like to stress that the longer these patients “of normal dependency needs” stay on hospital dialysis, the less likely they are to
go on home dialysis. Prolonged hospital dialysis might strengthen the antihome dialysis attitude; patients quite often regress on hospital dialysis or,
in other words, become more dependent and therefore less inclined to home
dialysis. Furthermore, the longer the patient is on hospital dialysis the
more he is exposed to the anti-home dialysis attitude of the medical team.
The Family
T h e family is the fourth factor to be taken into account when home
dialysis is considered. I n our unit their attitudes have often been more
negative than those of the patients. T o some extent we tend to regard this
as a normal phenomenon. We have mentioned the families’ anxiety about
taking on a role of a nurse or a technician. Furthermore, home dialysis is
a n additional work load on the family and a t times also a financial burden.
With some families, however, the resistance to home dialysis was more
extreme and usually did not appear in “predialysis” discussions but only
Resistance to Home Dialysis
217
when training was to start. These families also could not accept that the
responsibility for dialysis at home rests with the patient and not with them.
Their main objection to home dialysis was fear of not merely harming the
patient but often of killing him.
Observations gathered over the last two years have made us realize that
the families most fearful of harming the patient are those with strong unconscious aggression toward the patient. T h e two reports published so far
on family reactions (Shambaugh et al., 1967, 1969) have also reported the
impression that the handling of hostility is the greatest stress on the family.
A family’s aggression and methods of handling it depends usually on a
number of variables:
1. “Predialysis” level of aggression and methods of handling i t should
be mentioned since many patients reach dialysis after a long and
protracted illness. It is likely therefore that, as in families of chronic
patients, predialysis level of hostility in the family is high and its
direct expression minimal.
2. T h e patient’s adjustment to and on dialysis further influences the
family’s reactions to him. I n most families we have seen that the better the patient has adjusted (for example, continued to fulfill his functions and roles as before dialysis) the less frustrated, and therefore
less hostile, is the family.
3. We have noticed that guilt leelings in the family quite often make
them hostile. These guilt feelings may have their origin in the predialysis period in families who have (usually unrealistic) guilt feelings
of having caused the patient’s disease. These guilt feelings are often
reinforcctl by the medical team. When a patient does not adhere to
the diet, the family is scolded; when a patient does not go to work, the
family gets a lecture on the harmful effects of regression, and so on.
Especially where guilt feelings are concerned, there is a danger of
establishing a vicious circle-guilt leads to hostility, hostility increases
guilt feelings, and so on.
O u r limited findings so far seem to support these impressions. T h e
highest resistance to home dialysis was found in the three following
families. T h e husband of Patient 1 started out being dedicated, but after
he had influenced her decision for transplantation, unconscious guilt feelings increased. Overt aggressive behavior did not appear except in violent
outbursts over minor details and a n absolute refusal of a home dialysis
program. I n the second case (Patient 3) methods for expressing aggression
were totally lacking and a 101 of guilt was introduced by the medical team.
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Psychiatry I n Medicine
I n the wife of the third patient (Patient 6) all factors seem to have been
combined: predialysis level of aggression was high (though not diagnosed
a t that time), the patient regressed on dialysis, methods for handling of
hostility were lacking, and a lot of guilt was introduced by the team’s
attitude. O n the other hand, the best trained couple (Patient 4) has, at
times, endless fights concerning nearly all subjects but their partnership in
dialysis.
Our impression has been, therefore, that the “ideal” families for home
dialysis are not the dedicated ones, in whom dedication is often a reaction
formation to aggression and guilt, but those with little tendency to guilt
and high ability for verbal expression of aggression. Or, in other words, we
prefer the husband who can quarrel with his wife and then connect her to
the machine.
Financial Problems
Though the financial set-up of dialysis in Israel is quite unique, i t
should be mentioned since a t times it does play a role in the patient’s
going or not going on home dialysis. There is no national health insurance
in Israel, but nearly everybody has medical insurance which covers hospitalization. Hospital dialysis therefore has not cost any of our patients anything. Until now, these medical insurance companies have not agreed to
cover the installation of home dialysis, the cost of which, together with
the machine, is equivalent to an average income of three to four years. It
should be mentioned further that apartments in Israel are small and a
three-room (90-100m2) flat is well above average size.
I t can be stated therefore that the reality in this country weighs againsl
home dialysis and might prevent “good” patients from going home (Patients 4 and 7). On the other hand, the other factors mentioned above can
prevent transferring a patient to home dialysis when there are no financial
problems (Patients 3 , 6 and 8).
CONCLUSIONS
When we started our home dialysis program we believed that a t present
this was medically (physically and emotionally) the method of choice for
treating terminal renal failure. After the experiences described above, our
feeling is that as far as the physical condition of the patient is concerned,
this is the best treatment. T h e machines are safe and easy to handle; dialysis
at home offers the patient the optimal dialysis three times a week from eight
to nine hours instead of the minimal dialysis of twice a week for twelve
hours, which is all that most hospital units can afford.
Resistance to Home Dialysis
219
I n the beginning we also thought that home dialysis is emotionally the
best treatment, giving the patient maximal independence and flexibility and
minimal interference with everyday functioning and family life. Now, however, we have to qualify this statement somewhat; for the independent patient with the “right” family, who can participate emotionally in it, home
dialysis is the best. For the dependent patient, or the patient with the unconscious aggressive family, hospital dialysis might be less stressful.
We have presented our difficulties with training patients for home dialysis
and what we believe are the sources of these difficulties. However, we doubt
whether we have been able to cover all aspects of this complex and little
explored situation. We do not know how other units have managed to
avoid these difficulties, although the verbal reports oE many units seem
to be similar to our experience. I n the following we present some changes
which we believe can decrease some of these difficulties.
RECOMMENDAlIONS
1. Establish a separate training unit as has been done in a number of
centers. We do not believe that the importance of these separate training
units lies in the fact that they simulate the physical conditions of home.
We see their importance in having a separate medical team whose only
job (and ambition) is to train patients for home dialysis. By that, the
described resistance of a hospital team to home dialysis can be avoided.
Furthermore, by such a separate unit most of the “frightening” aspects of
hospital dialysis are avoided and the patient and his family can overcome
their normal fears of dialysis by mastering the machines and techniques.
2. Patients’ personalities can and should be evaluated before dialysis. T h e
“independent” patients should be selected for home dialysis; the “normally dependent” patients should be put on a training program as soon
as possible, and the “dependent” patients should be excluded from the
training from the beginning since failure with these patients increases
everybody’s doubts and resistance to home dialysis.
3. We realize the importance of evaluating the family and the family’s
relations. By the time the patient has reached the end stage of his kidney
disease the family, however, is often anxious and devoted, has “forgotten”
all past frustrations, and is ready to promise anything. Discussing home
dialysis with a family under such conditions is often misleading (as has
happened to us in two cases). A procedure for evaluating the personality
of the spouse and the family’s relations should be established. We sug-
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Psychiatry I n Medicine
gest that such a procedure should include a psychiatric and psychological
evaluation of the spouse as well as a number of conjoint interviews.
4. At present we have had to limit ourselves to what might be a partial
solution to the financial problem: a “self-service” unit is being built in
town. A machine will be available to each patient three days a week and
supplies given without charge, but the preparation of the machines and
the care of dialysis will be up to the families. We are of the opinion,
naturally, that the social condition of a country should promote, or at
least not hinder, home dialysis, but this is already beyond the scope and
purpose of the present report.
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Manuscript received January 24,1970