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Factors Of Adaptation And Rehabilitation In Home Hemodialysis

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Factors Of Adaptation And Rehabilitation In Home Hemodialysis

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Content FACTORS OF ADAPTATION AND REHABILITATION
IN HOME HEMODIALYSIS
by
Mary Ann Petrich Sviland
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Psychology)
June 1971
72-3798
SVILAND, Mary Ann Petrich, 1937-
FACTORS OF ADAPTATION AND REHABILITATION
IN HOME HEMODIALYSIS.
University of Southern California, Ph.D.,
1971
Psychology, clinical
‘ University Microfilms, A X E R O X Company, Ann Arbor. Michigan
*.
(P COPYRIGHT BY
Mary Ann Petrich Sviland
1971
THIS DISSERTATION HAS BEEN MICROFILMED EXACTLY AS RECEIVED
UNIVERSITY O F SO U T H E R N CALIFORNIA
T H E G R A D U A T E S C H O O L
U N IV E R S IT Y PA R K
L O S A N G E L E S , C A L IF O R N IA 9 0 0 0 7
This dissertation, written by
Mary Ann Petrich Sviland
under the direction of Dissertation C om
mittee, and approved by all its members, has
been presented to and accepted by The Gradu
ate School, in partial fulfillment of require
ments of the degree of
D O C T O R O F P H I L O S O P H Y
\T Dean
D ate June___1971
DISSERTATION COMMITTEE
j y , Chairman
........
■ ' /< ,)
PLEASE NOTE:
Some Pages have i n d i s t i n c t
p r i n t . Film ed as r e c e i v e d .
UNIVERSITY MICROFILMS
| ACKNOWLEDGEMENTS
I My heartfelt thanks to my dissertation committee
|for their continued helpfulness, encouragement, and moral
support which minimized the trauma of this undertaking. My
deepest gratitude to my chairman Albert R. Marston, Ph.D.,
Professor of Psychology and Psychiatry, Director of the
Ph.D. Program in Clinical Psychology, for his expert direc-
i
tion, warmth, and efforts to secure financial assistance.
My deep gratitude to Milton Wolpin, Ph.D., Associate
;Professor, for bringing his research expertise to this
I study and for directing my earlier research projects. My
deep gratitude to Benjamin H. Barbour, M.D., Associate
!Professor of Medicine, for generously giving of his time
and knowledge in directing the medical aspects of this
|paper.
Sincere appreciation is extended to the directors
of the renal dialysis units whose patients were used in
this study for their willingness to make their patients,
:medical records, and staff personnel available to me in a
spirit of mutual joint endeavor for the advancement of
^science. My thanks to: Benjamin H. Barbour, M.D., Director;
of the Southern California Renal Dialysis Rehabilitation
Center, LAC-USC Medical Center; John R. De Palma, M.D.,
I [
[Director of Dialysis, Cedars-Sinai Medical Center; Thomas
Gral, M.D., Acting Director of Dialysis, Cedars-Sinai
Medical Center; James H. Shinaberger, M.D., Chief of
Chronic Dialysis Unit, Veterans Administration Hospital
(Wadsworth); Richard J. Glassock, M.D., Chief, Division of ;
Nephrology, Harbor General Hospital; and Earle E. Newhart,
M.D., Director of the Hemodialysis Unit, Pasadena Community
Hospital.
My sincere thanks to Lee Baumel, M.D., Psychiatric
|Consultant for Cedars-Sinai Medical Center Dialysis and
|Transplantation Program, and to David Sanders, M.D.,
[Associate Director, Division of Psychiatry, Cedars-Sinai
[Medical Center, for proposing the study, generously assist-
l :
ing with the initial development of the study, and funding
the earlier phases of this research.
A study of this magnitude is only possible through
!the help of many dedicated people. I am deeply indebted to
many professional friends who freely gave of their time and |
expertise to make this study possible. It was a privilege
and pleasure to work again with them. My warmest thanks to [
Hedda Bolgar, Ph.D., Chief Psychologist, Director, Clinical
Psychology Training Program,- Cedars-Sinai Medical Center, ;
j
[for helping to design and supervise the study and for j
enlisting the necessary aid of others on this project. My
warmest thanks also to my previous thesis chairman Donald C.
;Bulter, Ph.D., Biostatistical Consultant, Western Research
Support Center, VA Hospital, Sepulveda, for directing and
conducting the statistical analyses of this research. My
thanks to Henry L. Jorgensen, Chief, Data Processing
Section, Western Research Support Center, VA Hospital,
Sepulveda, for efficiently and rapidly processing the data.
My special thanks to Joan F. Zahig, B.A., Reference
Librarian, Biological and Medical Sciences, Veterans
Administration Hospital (Wadsworth), for locating obscure
I journal articles.
My co-workers at the Veterans Administration
i
'Hospital (Wadsworth) also merit recognition for their
helpfulness. My thanks to Allan E. Edwards, Research
Psychologist, who helped in the development of some testing
procedures. My thanks to Maxime W. Meldrum, MSW, Research
Social Worker, who shared her knowledge of patient psycho
logical behavior and family relationships. Finally, my
grateful thanks to my clinical supervisor, James W.
McKelligott, Ph.D., Chief, Psychology Service, Veterans
: Administration Hospital (Wadsworth), for giving me moral
support and needed flexibility of work hours to facilitate
;data collection.
My appreciation to the Veterans Administration for
Iprocessing the data at the Western Research Support Center.
My appreciation also to Cedars-Sinai Medical Center for
'support from the General Research Support Grant RR 05468.
i I should like to thank my typist Mrs. Valeria
;Pohlmeyer for her professionally proficient and expeditious:
ityping of this lengthy manuscript. I am also indebted to
all the other people, including physicians, social workers,!
nurses, staff technicians, and secretaries, who helped
supply data for this project. My special thanks to all the;
patients and their families for generously participating in;
this study.
j Finally, a debt of gratitude is acknowledge to my
j
|mother, Mrs. Ann Petrich, for her encouragement and help
|with personal responsibilities to free my time for research!
i
J I am very grateful to my wonderful children Laura Denise
!Sviland and Gregory John Sviland for their patience, under-I
| standing, moral support, and acceptance of recreational
I |
I restrictions during the process of completing this research!
v
TABLE OF CONTENTS
ACKNOWLEDGEMENTS
LIST OF TABLES
Chapter
I. PROBLEM ......................................
II. LITERATURE REVIEW OF BACKGROUND INFORMATION .
Kidney Function and Renal Disease
History of Hemodialysis
Description of Hemodialysis
Dialysis Machines
Predialysis Symptoms
Transient Symptoms during Dialysis
Transient Symptoms Following Dialysis
Chronic Medical Complications
Medical Problems of Uremia
Medical Problems Caused by Dialysis
Treatment
III. LITERATURE REVIEW OF HOME HEMODIALYSIS:
PHYSICAL ASPECTS ...........................
Background and Advantages of Home Dialysis
Home Training
Predictor Variables Related to Dialysis
Schedule and Training
Patient Involvement
Shunt Criteria Variables
IV. LITERATURE REVIEW OF HOME HEMODIALYSIS:
PSYCHOLOGICAL ASPECTS .....................
Introduction
Psychological Stresses
Psychological Process during Dialysis
Body Image
Emotional Reactions
Defense Mechanisms
Dependency
| Chapter Page j
Psychiatric Disorders I
Effect on Spouse and Family j
Psychological Adjustment j
Management and Staff Implications
V. LITERATURE REVIEW OF REHABILITATION......... 101 !
Work Rehabilitation
Sexual Functioning
Physical Activity and Social Involvement
; Rehabilitation Variables j
: VI. REVIEW OF SELECTION CRITERIA LITERATURE . . . 113 j
| Reported General Selection Criteria j
! Reported Sociological Selection Criteria ]
Reported Psychological Selection Criteria
Criteria Specific to Home Dialysis
Arguments Against Proposed Selection |
Criteria j
VII. METHOD........................................ 139
Introduction
Subjects
Procedure
Psychological Tests
i Predictor Variables
I Criteria Variables
Pretest of Procedures
I Statistical Design and Analysis
j Function of This Study
i
VIII. DESCRIPTIVE RESULTS ......................... 164
i
Introduction
Characteristics of the Patient Population
Conclusions about Selection Determinants
Predialysis Characteristics
Hospital Hemodialysis and Training
Management Problems for the Staff
| Dialysis-Related Characteristics
| Financial Aspects of Dialysis
Transient Symptoms during Dialysis
Transient Symptoms on the Day Following
| Dialysis
Current Medical Information
| Current Neuropathy Information
vii
Page
Chronic Medical Complications
Shunt Information
Dietary Adherence
Adequacy of Dialysis
Rehabilitation Information
Psychological Well-Being
Effects of Dialysis on the Spouse
Psychological Test Results
IX. RESULTS OF MULTIPLE REGRESSION ANALYSES . . .
Introduction
Patterns of Results
Multiple Regression 1. Use of Psychological
Tests to Predict General Hemodialysis
Adaptation and Rehabilitation Criteria
Multiple Regression 2. Use of MMPI Scales
to Predict General Hemodialysis Adaptation
and Rehabilitation Criteria
Multiple Regression 3. Use of Selection
Criteria to Predict General Hemodialysis
Adaptation and Rehabilitation Criteria
Multiple Regression 4. Dialysis and Medical
Factors Relating to Job Rehabilitation
and General Activity
Multiple Regression 5. Dialysis, Medical,
and Personal Factors Relating to Sexual
Performance
Multiple Regression 6. Dialysis, Medical,
and Personal Factors Relating to Shunt
and Dietary Adherence Problems
Multiple Regression 7. Dialysis and Medical
Factors Relating to Transient Symptoms
during and after Dialysis
Multiple Regression 8. Dialysis and Medical
Factors Relating to Chronic Medical
Complications
Multiple Regression 9. Treatment Hospital
and Machine Factors Relating to Transient
and Chronic Medical Complications
X. DISCUSSION ....................................
A Priori Hypotheses Findings
Significance of Psychological Defense
Mechanisms to Adaptation and Rehabilita
tion Criteria
viii
i
]
208 ;
290 !
I
Chapter Page
The Validity of Nonmedical Selection
Criteria Variables to Successful
Adaptation and Rehabilitation
Comments on Sexual Functioning
Implications for Healthy Spouse Adjustment
The Need for Psychic Distance: Job
Rehabilitation Implications
The Dialysis Machine as an Entity
The Need for Patient Responsibility for
Dialysis
Implications for Psychotherapy with
Dialysis Patients
Implications for Home Training
Implications Regarding Past Research
Findings
Implications for Future Research
REFERENCES.......................................... 322
APPENDICES.......................................... 336
LIST OF TABLES
!Table
t
! 1.
2 .
3.
4.
6.
i
i
| 7.
i
I
|
i
| 8.
Page
Significant t : Values on the Regression
Coefficient for Psychological Test
Predictors of General Adaptation and
Rehabilitation Criteria ..................... 214
j
Significant t_ Values on the Regression
Coefficient for MMPI Scale Predictors j
of General Adaptation and Rehabilitation j
Criteria 222 j
i
I
Significant _t Values on the Regression I
Coefficient for Selection Criterion j
Variables to General Adaptation and |
Rehabilitation Criteria..................... 231j
Significant t : Values on the Regression j
Coefficient for Dialysis and Medical j
Variables to Employment and Activity
Rehabilitation Criteria..................... 2411
Significant jt Values on the Regression
Coefficient for Dialysis, Personal, and
Medical Factor Variables to Sexual
Performance Criteria ......................... 246
Significant _t Values on the Regression
Coefficient for Dialysis, Medical, and
Personal Factor Variables Relating to
Shunt and Dietary Control Criteria .......... 253
Significant jt Values on the Regression
Coefficient for Dialysis-Related and
Medical Predictors to Transient
Symptoms during Dialysis Criteria ............ 263
Significant jt Values on the Regression
Coefficient for Dialysis-Related and
Medical Predictors to Transient
Symptoms on the Day Following Dialysis . . . 264
x
Table Page
9. Significant _t Values on the Regression
Coefficient for Dialysis and Medical i
Predictors to Chronic Medical
Complication Criteria ....................... 276
10. Significant jt Values on the Regression
Coefficient for Hospital and Machine
Predictors to Transient and Chronic
Medical Complication Criteria ................ 288
xi
CHAPTER I
| PROBLEM
| Long-term hemodialysis as a practical treatment for
jchronic renal failure has only a ten-year history. A recent
U.S. Public Health Service report estimated that 2,400
people are currently on chronic dialysis in this country. |
Of this group, 1,700 were being treated at a hospital and j
700 were on home dialysis programs (Cummings, 1970). j
!
No systematic research has been undertaken to date !
on factors of adaptation in home dialysis patients. The j
rationale behind the approach of this study was that success:
|
of adaptation to a hemodialysis program probably depends on I
I
many interrelated medical, dialysis procedural, and psycho- !
logical factors. An overview study exploring the inter
relationships of many potentially relevant variables is
necessary before systematic, controlled research can be
directed to specific aspects of adaptation. This study was
'one of the first major attempts to uncover relationships
I
i
between patient information and objective criteria of good
adaptation to the home dialysis treatment program.
As a first step in understanding adaptation, which
has value for both current patient management and for valid
1
2 !
selection processes, both the predictor and criteria vari
ables must be objectively defined and statistically analyzed
jfor relationships. Criteria variables were selected in this
jstudy on the rationale that cooperation or adjustment could
I
be behaviorally defined as a minimum or absence of transient
or chronic medical complications and by rehabilitation.
Better adaptive patients would then be differentiated from
poorer adaptive patients by a lesser incidence of medical
complications and by a resumption, as much as realistically ;
possible, of the previous life style. A distinction may be i
I
necessary between treatment program adaptation and rehabili-|
i
tation since some rehabilitated patients are treatment j
i
rebels while some cooperative patients are overly dependent i
and unable to rehabilitate (Norris, 1968).
The first goal of this research was to attempt to
define significant patient characteristics relating to
differences in many aspects of adaptation to a home hemo-
jdialysis program. A cross-sectional study was undertaken
jusing approximately 40 patients in the greater Los Angeles
Jarea currently on home hemodialysis from five treatment
|
centers. A wide range of 96 items of patient information
was examined for relationships to 78 objective treatment
criteria.
Patient information used as predictor variables
included: personal data, illness-related data, psycholog
ical test scores, spouse supplied information, and staff
ratings. Adaptation criteria included measures on: j
' i
biochemical control, cannula problems, dietary adherence,
transient symptoms during and following dialysis, chronic
i
medical complications, and organic brain pathology.
Rehabilitation criteria included measures on: employment,
j
|sexual functioning, activity level, and psychological
well-being.
The second purpose of this study was to examine the
relationships of frequently used nonmedical selection
variables to adaptation on home hemodialysis. Systematic i
investigation of the validity of nonmedical selection vari- j
ables has been a neglected area of hemodialysis research. j
To this end, this study examined most of the major selection
criteria previously used or reported in the literature as
important to adaptation.
A selection process is necessary for admission to a
hemodialysis program because current facilities are grossly
inadequate to serve patient needs. The Gottchalk Committee
estimated that even under strictest medical criteria a
minimum of 6,300 to 8,500 new "ideal candidates" would be
available in fiscal 1970. Of these, 750 would receive
jtransplants and 1,443 would enter a chronic dialysis
program. Between 4,100 and 6,300 candidates would be left
I
to die (Schreiner, 1969).
I
! The high costs of hemodialysis coupled with a lack
of government funding or medical insurance coverage prevents
necessary expansion of treatment centers. Existing hemodi- j
!
alysis facilities are forced to select for treatment a small
'percentage of available applicants. Medical evaluations are
'generally used to select patients. Some centers also base
i
Sselection on psychiatric, social-worth, or financial evalua
tions made by a medical or lay committee or both. Sanders
and Dukeminier (1968) ask if constitutional rights of equal
protection and due process are violated where selection
committees occur.
Sidestepping the legal issues of current selection !
practices, the aspect of biases in selection is a relevant
issue for investigation. The selection process has received
little written attention and conscious and unconscious I
biases become involved in choosing candidates (Abram, 1968)J
Biases can creep into a selection process since selection
variables have not been objectively defined nor validated
|against objective criteria measures of adaptation.
Some of the nonmedical criteria either frequently
used in selection or viewed as necessary selection require
ments for dialysis adaptation include: (a) maximum age of
45 (Hampers & Merrill, 1966; Schribner, 1963); a maximum age
cutoff is currently being relaxed in many treatment centers,
(b) intelligence (Gombos, Lee, Harton & Cummings, 1964;
Hampers & Merrill, 1966; Retan & Lewis, 1966; Sand,
Livingston & Wright, 1966), (c) stability and emotional
i maturity (Gombos et al., 1964; Hampers & Merrill, 1965;
Retan & Lewis, 1966; Schribner, 1963), (d) cooperation
(Schribner, 1963); in 1965, Schribner, Fergus, Boen and j
Thomas stated that picking the cooperative patient is a far
more important selector than the other needlessly rigid
i
[criteria they originally proposed, (e) stability of family
and marriage (Gombos et al., 1964; Sand et al., 1966), and
■(f) mechanical ability (Shaldon, 1968); Shaldon stated that
mechanical ability was important for home dialysis success. |
There is no empirical evidence that previous selec- |
tion criteria are objectively measurable or that they
differentiate patients on adjustment. The uremic syndrome I
includes psychological symptoms ranging from irritability
i
to severe depression or psychosis which confounds an j
attempted assessment of the patient's stable personality j
following dialysis.
Recent studies indicate that age and intelligence
^selection criteria may be needlessly rigid (Shaldon, 1968b;
jwood, 1969). Furthermore, although Sand et al. (1966) found
s
intelligence to be related to adjustment, adjustment was
measured by staff ratings which, as subjective measures,
could have biased the results. No minimum required func
tioning level of intelligence has been established.
Currently many hemodialysis centers are admittedly
biased in selecting patients on the basis of intelligence
|
jcomparisons. Regarding prediction of adjustment, patients
jevaluated as poor risks have shown exceptional strength and
coping ability while other seemingly stable patients have
had psychotic-like disturbances. j
On the basis of experience or previous hemodialysis
jliterature, the following a priori hypotheses were expected
|to be substantiated by the results obtained in this study:
(a) Length of time of home hemodialysis treatment
will significantly correlate with criteria variables,
especially medical complications.
(b) Transient symptoms during dialysis will prima- !
rily be a function of the type of dialyzer. Patients using !
a parallel plate dialyzer would have less transient symptoms
than patients using a coil dialyzer. i
(c) Signs of organic brain pathology such as impair-j
i
ment of immediate memory function occur in dialysis patients
and may be a function of length of time of dialysis treat
ment or length of elapsed time between onset of renal
failure and first dialysis.
(d) A maximum age cutoff of 45 as a selection
;criterion has been too rigid and lacks validity as a
I
jpredictor of adaptation. It is expected that patients over
;45 years of age will not show significantly worse adaptation
than patients under 45 years of age.
(e) A minimum intelligence quotient, probably in the
average range of intelligence, is necessary for successful
adaptation in home hemodialysis. Beyond this minimum
putoff, intelligence does not correlate positively with
adaptation success.
(f) Patients who direct aggression to frustration
iinwardly instead of outwardly will have more shunt or
I
dietary problems. Therefore, a higher intropunative score
on the Rosenszweig P-F Study, which measures direction of
aggression to frustration, will correlate positively with
frequency of cannula or dietary problems.
(g) Staff attitude towards the patient as measured
by ratings of patients from the staff questionnaire will
correlate positively with successful adaptation.
(h) More satisfactory emotional support from the
family, obtained from information supplied by both the
patient and his spouse or parent, will correlate positively
with successful adaptation.
A third purpose of this study was the obtainment of
objective information on the absolute incidence of various
life characteristics of a large sample of home hemodialysis
patients. This information has been previously available
only from a small sample of patients or through subjective
I
^peculation. This information could indirectly help in
understanding and decreasing ongoing home hemodialysis
iproblems among the patients. Success of adaptation could
then be increased in process as well as through improved
selection practices.
It was hoped that this exploratory research on home
i
I
hemodialysis would uncover promising areas for further,
’ controlled research which would result in a decrease in the I
i
icurrent incidence of dietary, cannula, dialysis inadequacy,
and medical complications and also increase the objectivity
and validity of the selection process.
Dialysis is a medical treatment that has far-
reaching consequences in all aspects of the patient's life.
iThe following chapters will review the literature on phys
ical and psychological aspects of dialysis, rehabilitation,
and selection. This will provide a comprehensive foundation
for understanding the interrelated factors involved in
dialysis problems and patient adaptation.
CHAPTER II
| LITERATURE REVIEW OF BACKGROUND INFORMATION
Kidney Function and Renal Disease
j The kidney is generally thought of as an excretory
organ since it makes urine. However, its primary function
is to regulate the volume and composition of body fluids,
especially blood plasma and other extracellular fluids. Itj
is also involved in red cell formation, metabolic activi- |
ties, and regulation of other body functions such as blood |
j
pressure (Levinsky, 1965). j
The human kidney filters the entire plasma volume j
i
25 times each day. Most water and other materials that are j
normal components of plasma are returned to the circulation
to avoid depletion of fluids. The kidneys are able to vary
ireabsorption and excretion of normal plasma components to
jmaintain a stable plasma composition irrespective of wide
[Variation in diet composition and bodily metabolism
(Levinsky, 1965).
When the damaged kidney loses selective filtering
function, chemical elements may be excessively retained
instead of passed. Large protein molecules, red cell casts,
red cells, or white cells may be excreted instead of
10 I
normally retained. An excessive presence of these compo- J
nents in the urine is a sign of abnormal kidney function andj
is a means of discovering renal disease (Levinsky, 1965).
| The damaged kidney loses its ability to regulate
body fluid and a reduced urine output develops. Oliguria is
the definition for urine output less than 400 ml. per day.
Anuria is the definition for urine output between 0 to 100
I
ml. per day (Schreiner, 1963). Since renal function deteri-j
orates in all patients at varying rates, creatinine clear- |
ance is a biochemical measure used to assess the residual
I
renal function (Hendler, Elgin, Hendler, Cummings, Vietzke, !
Hinckley & Gombos, 1967).
With reduced salt and water excretion in kidney
failure, edema, or excessive fluid, collects under the skin,!
in body tissues, and in body cavities such as the chest and j
lungs where it may seriously affect breathing (Levinsky,
L965). Edema also results from heart failure or plasma
protein deficiency (Reiman, 1963).
|
| Uremia defines a clinical syndrome occurring in
|
renal failure when kidney function is markedly reduced
through any acute or chronic disease. Uremia involves:
(a) failure to remove waste products, (b) inability to
maintain the normal volume and composition of plasma and
|other extracellular fluids, (c) malnutrition, (d) hyperten-
i
jsion, and (e) anemia (Levinsky, 1965). Bone disease also
j
bccurs.
Causes of chronic renal failure include: (a)
| I
chronic glomerulonephritis, (b) chronic pyelonephritis, i
(c) nephrotic syndrome, (d) polycystic kidney disease,
j (e) malignant hypertension, (f) diabetic nephropathy, (g)
myelomatosis, (h) amyloid disease, (i) polyarteritis
inodosum, and (j) systemic lupus erythematosus (Rawnsley,
1970a).
The most noticeable early symptoms of chronic
uremia are lassitude and mental depression. Vigor and
mental alertness gradually decrease over a period of weeks, j
months, or even years. Finally the state of torpor and i
confusion leads to terminal restless semicoma which may be j
punctuated by transient episodes of lucidity or agitated '
psychotic behavior. Common neuromuscular phenomena include:
twitching, muscle weakness, cramps, or neuritis-like pains
in the extremities, and convulsions. Often a diffuse
degeneration and loss of nerve cells in the cerebral cortex
and brain stem occurs which is probably due to biochemical
disturbances in brain metabolism. It is not known if the
psychiatric or neuromuscular manifestations of uremia
relate to brain pathology (Levinsky, 1965; Reiman, 1963).
The most distressing symptoms of uremia involve the
gastrointestinal tract. Anorexia is a common early symptom.
lLater frequent attacks of nausea and/or vomiting occur
jespecially following breakfast. The increased vomiting and
Idistastefulness of food may make oral feeding impossible
I ~ " ~ .. ’ 12~ 1
I j
land lead to malnutrition. Intractable hiccoughing or
I I
'diarrhea may develop (Levinsky, 1965; Reiman, 1963).
| In its advanced stages urinary pigmentation deposits
i ;
I in the skin produce a yellow-brown skin pigmentation. The
urochrome pigmentation of the uremic patient may persist
Iwhen the blood-urea has fallen to normal for as long as
|four months following regular hemodialysis (Shaw, Bazzard,
I Booth, Nilwarangkur & Berlyne, 1965). i
i i
| Sometimes urea crystallizes out of the sweat to
I ;
produce a white powdery material clinging to the skin and
;hair of the face and chest. Intense pruritis is common and
i
jthe itching may be unbearable. Pupuric and petachial
I lesions of the skin and recurrent bleeding from the gums,
inasal mucosa, or gastrointestinal tract are common and due
:to increased capillary fragility or coagulation defects
from abnormal platelet function (Reiman, 1963).
Cardiovascular disorders, especially hypertension,
|are common in chronic uremia. High blood pressure in renal
idisease may be based, in part, on the excessive amounts of
angiotensin released by the damaged kidney which causes
blood vessels to narrow. Hypertension may cause renal
I disease so a vicious circle can result in which hypertension
[from renal disease aggravates the renal disorder. Severe
-hypertension can result in congestive heart failure which i
! I
also decreases kidney function and results in rapid deteri- ;
j
oration of the clinical state (Levinsky, 1965). j
13 i
Most patients with uremia develop anemia which
results in pallor of the nail beds and mucous membranes j
(Reiman, 1963). With control of uremia through hemodialy-
jsis, anemia remains one of the most intractable symptoms.
i
|Complete chemical control of a uremic patient by hemodialy-
!
Isis generally results in reversal of many clinical features
of uremia except anemia, unexplained peripheral neuropathy,
and calcium deposition in tissues (Schreiner, 1963). Bone I
disease and irregular hypertension may also persist.
In the past uremia was a rapidly progressive, fatal j
disease. Hemodialysis and kidney transplant are two
i
approaches developed in the last decade for prolongation of I
life in terminal renal failure. Homotransplantation of
human kidneys replicates original, continuous kidney func- j
tion and allows the patient free mobility. Its treatment
use is currently limited due to tissue immunity reactions
causing rejection of the transplant kidney and due to the
gross lack of availability of donor or cadaver kidneys.
Hemodialysis, utilizing an artificial kidney, is the alter
nate treatment approach. However, hospital hemodialysis
I
jrequires expensive machines, hospital space, and specially
trained medical personnel. The cost of inpatient treatment
can run as high as $28,000 per year (Sanders & Dukeminier,
i 1968) . Operational costs and lack of funding may hinder
jnecessary hemodialysis program expansion. However,
I
jphysicians themselves are not in favor of performing
long-term dialysis on all patients with chronic uremia
despite the fact that it would prolong life and financing
Iwas assured (Brown, Bulger, Laws & Thompson, 1970).
The current utilization of kidney transplants or
I
|dialysis is woefully inadequate. By 1969 in the United
i
!States 2,000 kidney transplants had been performed while
more than 1,500 patients had been treated by dialysis
(Schreiner, 1969). However, due to facility limitations,
less than 1-3% of the available patients are receiving !
I
intermittent hemodialysis and kidney transplants (Figueroa,j
I
1969; Schreiner, 1968). j
I
In 1964 United States death certificate statistics
listed 27,345 deaths directly due to renal failure and j
approximately 70,000 deaths due to hypertension which i
involves kidney function (Schreiner, 1969). Therefore, it
is estimated that between 60,000 and 100,000 Americans die
each year of uremia of which a large percentage must be
!over 50 years of age (Figueroa, 1969). As previously
stated, between 6,000 and 8,000 of these people with end
I stage renal failure would be highly suitable candidates for
hemodialysis or transplantation.
History of Hemodialysis
' Hemodialysis is a treatment for renal failure in
|which a machine, or artificial kidney, externally filters
j
I the body blood supply and adjusts its fluid content. The
15 I
first dialyzer, or artificial kidney, was built in a labor-
: j
atory by Rowntree and Turner in 1913 (Schribner, Buri,
Caner, Hegstrom & Burnell, 1960).
I By 1944 Kolff made dialysis clinically feasible.
jHe began development of an artificial kidney in 1938 after
j
!a poignant, Netherlands hospital episode in which he had to
inform a farm mother that her only son was dying of renal j
failure. He later formulated that life might be possible j
if only 20 grams of urea and other retention products could|
I
be removed daily. During the Nazi occupation, he developed
the first rotating drum, artificial kidney with the secret ;
help of the town's largest factory (Kolff, 1965).
During the war years, Kolff had built eight artifi-|
i
cial kidney machines. By 1946 Kolff had reported on 15 I
patients (Schreiner, 1968). As soon as transportation was
possible after the war Kolff distributed four machines to
:hospitals in London, New York, Montreal, and Poland (Kolff,
1965). In 1950 Kolff moved to Cleveland and devised the
I prototype for the twin coil dialyzer from fruit cans and
cellophane (Kolff, 1965).
By 1960 hospitals around the country were actively
involved in hemodialysis research. Chronic intermittent
hemodialysis became a practical treatment for patients in
jend-stage renal failure with the development of the arterio-
I
! venous Teflon shunt by Quinton, Belding and Schribner in
|1960 (Pendras & Erickson, 1966). On March 9, 1960
1 6 !
Schribner in Seattle launched the first, still living, |
chronic uremic patient on maintenance dialysis (Schreiner,
1968).
i
]
|
Description of Hemodialysis
i
| Hemodialysis consists of passing the patient's
blood system extracorporally through a dialyzer or artifi
cial kidney. The dialyzer then repairs the abnormal blood |
i
composition of the uremic patient through the use of a
j
semipermeable membrane placed between the blood flow and
the dialysate, or surrounding bath fluid. During dialysis j
constituents of the blood and dialyzing fluid are exchanged j
through the semipermeable membrane by the process of
diffusion. Substances in high concentration on one side of j
the membrane pass through the membrane to the other side
until concentrations between the blood and bath are equal I
(Figueroa, 1969; Hampers & Schupak, 1967).
In this way substances of abnormally high, debili
tating concentration in the uremic patient's blood are
jremoved. Substances of abnormally low concentration in the
patient's blood are added from the bath. Urea, creatinine,
potassium, phosphate, uric acid, and other amino acids are
removed from the blood stream. Certain substances such as
calcium and bicarbonate are added to the blood stream
(Hampers & Schupak, 1967).
j The pore diameter of the membrane allows these
diffusible molecules to pass through freely. However,
proteins and erythrocytes, among other blood constituents,
are retained in the blood stream because their size exceeds
I
ithe pore diameter of the membrane (Figueroa, 1969; Hampers
j& Schupak, 1967).
The blood supply is continuously circulated through
the dialyzer during the course of dialysis treatment. The
bath fluid may be constantly replenished which is called a
"single pass" or it may be changed every few hours.
Substances removed from the blood by the dialyzer enter the i
i
blood stream from cells. The blood is then constantly
replenished and the dialyzer affects the whole body concen- j
tration of substances (Hampers & Schupak, 1967). j
j
Patients with renal failure have excessive fluid !
I
I
retention. Water and salt excess is removed during dialysis
by ultrafiltration. When pressure is exerted on fluid
within the membrane which exceeds the pressure within the
bath, a net loss of fluid from within the membrane, or
!
iultrafiltration, occurs (Hampers & Schupak, 1967).
The patient's blood supply is connected to the
dialyzer by means of the arteriovenous shunt. A subcutane
ous cannula is placed in the artery of the patient's leg or
forearm which is connected by a shunt to a subcutaneous
|
jcannula inserted in a vein. The shunt, which acts as an
jartificial blood vessel, circulates the blood outside the
i
|body from the artery to the vein. During hemodialysis the
r" ~ ' ’ 18
i shunt is removed and the arterial and venous cannulas are !
connected to the machine. The blood flows from the arterial
cannula through the dialyzer and is returned to the patient
|through the venous cannula. Most cannulas used are essen
tially permanent and may remain for many months before
replacement is required.
The patient is attached to the machine for six to
twelve hours during each dialysis. During this time he can
read, watch television, or sleep. Two or three dialyses !
]
are required per week. j
Dialysis Machines
Most kidney machines in operation today are modifi-j
cations of two basic designs of the semipermeable membrane, j
namely a parallel-plate dialyzer or a coil dialyzer
(Hampers & Schupak, 1967). In the parallel-plate dialyzer,
I the blood flows between two rectangular sheets of cello-
Iphane mounted in a rigid frame. In the coil dialyzer, the
; blood flows through two parallel cylindrical lengths of
cellulose tubing enclosed in a canister. With both models
the bath fluid surrounds the membrane. To prevent the
blood from coagulating in the external circuit, heparin is
injected into the arterial line through which the blood
|
enters the dialyzer (Hampers & Schupak, 1967).
The coil dialyzer has the following advantages over
the parallel-plate dialyzer. It is compact, disposable,
and simple to assemble and prepare for dialysis which
■ greatly reduces maintenance time and space needed for |
assembly. It is mass produced and the cost of initial
j
|equipment and disposable supplies is relatively low. It
ihas a relatively high degree of efficiency and dialysis
I
time is generally shorter than with some parallel-plate
;dialyzers (Eschbach, Barnett, Daly, Cole & Schribner,
1967).
The actual cost of supplies with a parallel-plate
dialyzer may be less than the costs with a coil dialyzer.
i
A Kidney Disease spokesman has estimated the cost of home j
dialysis with coil equipment at $16,796 for the first year j
and $7,906 for the second year. His estimates for
comparable costs with a parallel-plate are $18,635 and
$6,670 (Cummings, 1970).
However, the coil dialyzer has some major disadvan-
itages which results in the parallel-plate dialyzer being
Imore widely used (Eschbach et al., 1967). First, the coil
!
!dialyzer requires blood priming for operation. This
j
necessitates either storage of blood collected at the
conclusion of dialysis or priming directly from the patient
at the onset of dialysis which results in rapid shifts of a
large volume of blood. If the latter method is used, a
rapid blood volume shift can enhance transient medical
symptoms during dialysis. Also a blood pump is generally
required with the coil dialyzer to overcome the resistance
of blood flow through the coils. A blood pump is rarely
used with the parallel-plate dialyzer, except with veni
puncture shunts. The low resistance of the parallel-plate
j
|dialyzer allows the patient's cardiac output to provide
i
|the necessary blood flow tinder normal operating conditions.
A blood pump has been reported to decrease cannula life and
affect red cells and platelets which may lead to anemia and
i
; !
bleeding problems; however, these effects have not been j
established (Eschbach et al., 1967). i
United Kingdom centers primarily use a single-pass,
modified parallel-plate dialysis system (Wright, Goldsmith !
& Semple, 1969). But one center switched to a coil
dialyzer because of its shorter dialysis time and its !
disposable supply features which both increased the patient
load per day and eliminated hospital space required for
rebuilding which the parallel-plate dialyzer requires
(Macrae, Walley & Parker, 1969).
Proponents of the parallel-plate dialyzer have
i
emphasized its enhancement of patient well-being with fewer
(experienced transient symptoms during dialysis (Tsaltas,
I
j1967). The parallel-plate dialyzer is also more commonly
preferred because it does not require a blood pump or
blood priming and blood pressure in its extracorporeal
(Circuit is easily monitored (Eschbach et al., 1967). By
|
jstoring and reusing the dialyzer and blood tubing three
I
i
Jtimes, assembly of the parallel-plate dialyzer can be
21
decreased to once per week with a 30% reduction in labor
and $900 per year in costs (Eschbach et al., 1967).
Successful reuse of the coil dialyzer can also lower costs
jwith the coil equipment.
i
I Predialysis Symptoms
|
An attempt is made to begin dialysis treatment for
those patients with renal failure accepted to the program
before the chronic severe medical complications of uremia
become entrenched or irreversible. However, due to the
toxicity of excessive concentrations of some substances,
patients maintained on hemodialysis may differentially
exhibit various uremic symptoms on the day preceding
dialysis.
Symptoms experienced prior to dialysis for ongoing
dialysis patients include: apathy, disinterest, fatigue,
lethargy, lack of alertness or concentration, headaches,
|thickened speech, muscle weakness leading to walking
difficulties, extreme restlessness, severe leg pains or
icramps, nausea, loss of appetite, vomiting, pruritis, edema,
hypertension, and quite infrequently uremic tremors or
vision difficulties including blurredness or blindness
(Barber, Nakamoto, McCormack & Kolff, 1963; Brown, Maher,
iLapierre, Bledsoe & Schreiner, 1962; Curtis, 1968; Hegstrom3
jMurray, Pendras, Burnell & Schribner, 1962; Kolff, 1965;
Schribner et al., 1960).
22
Hyperkalemia, or excessive potassium concentration,
|is present in many patients beginning dialysis treatment
-and results in muscle weakness or difficulty in maintaining
i
I
|grasp (Hegstrom, Quinton, Dillard, Cole & Schribner, 1961;
!
jSchlotter, 1970). Vomiting prior to dialysis occurs with
i
jan excessive concentration of creatinine, uric acid or
phosphorous and its occurrence following onset of dialysis
treatment indicates inadequate chemical control (Brown et
al., 1962; Keleman & Kolff, 1960). An elevated serum
creatinine level produces predialysis symptoms of slowed
mental process, hesitant speech, double vision and/or
pyramidal tract signs (Brown et al., 1962).
Experienced symptoms can be reduced by scheduling
more frequent dialyses for shorter durations. Three
dialyses per week for six hours each is considered more
effective for maintaining patient well-being than two
dialyses per week for nine hours each. However, even with
adequate dietary and biochemical control through frequent
|dialyses, patients commonly feel "out of sorts" on the day
preceding dialysis. This is due to toxic build_up and may
be manifest simply as lethargy, fatigue, impaired concen
tration, or headaches.
23 :
Transient Symptoms During Dialysis
During dialysis patients differentially experience
transient symptoms including: nausea, vomiting, leg muscle
icramps, dizziness, headaches, sleepiness, restlessness,
I irritability, cardiac irregularities, hypertension, or
i
ihypotension. These symptoms are a function of the type of
dialyzer and of rapid changes in chemical balance. However, 1
[
the psychological state of the patient can, somewhat, !
affect their occurrence or severity (Shea, Bogdan, Freeman j
& Schreiner, 1965). Therefore psychological as well as
physical components are involved in transient symptoms. |
i
A rapid shift in chemical balance has been suggested
as a cause of the so-called disequilibrium syndrome. !
Symptoms of the disequilibrium syndrome include: severe j
headaches, muscle twitching or tremors, disorientation, |
nausea, vomiting, hypertension, and cardiac irregularities
; (Sokol, Gral 6 c Rubini, 1967; Wakim, 1969). The disequili
brium syndrome is found in the early weeks of dialysis but
jean reoccur with increased protein intake (Sokol et al.,
11967). Patients generally recover.
j
| The disequilibrium syndrome involves an increase of
|
intracranial pressure during or shortly after dialysis due
to cerebral edema. Cerebral edema is attributed to a
slower diffusion of urea from the brain. Dialysis decreases
|the urea concentration more rapidly in the extracellular
|compartments of the body than in the intracellular
compartments. A resulting osmotic gradient across the cell
I
membranes draws fluid into the cells, especially cerebral
'cells. Cerebral edema and the disequilibrium syndrome then
|occurs (Maher, Freeman & Schreiner, 1965; Sokol et al.,
11967).
Wakim (1969) proposed that hypoatremia, or low
sodium, is the triggering mechanism in stimulating manifes
tations of the disequilibrium syndrome. Glucose is added
i
j
to the dialysis bath fluid to minimize osmotic transfer
i
(Sokol et al., 1967). j
i
Vomiting during dialysis has been attributed to the j
high calcium content of the water in the bath fluid result- j
ing in the removal of calcium from the body and acute
hypocalcemia (Curtis, Eastwood, Smith, Storey, Verroust,
de Wardener, Wing & Wolfson, 1969).
Symptoms during dialysis can be a function of the
|type of dialysis machine used. Generally more severe
jsymptoms including nausea occur more frequently with the
| coil dialyzer than with the parallel-plate dialyzer
(Tsaltas, 1967). This may, in part, be due to the more
rapid shift in blood composition with the more efficient
coil machine.
25
Transient Symptoms Following Dialysis
Although the techniques and details of hemodialysis
are well established, some patients show a transient
jdeterioration in their general condition at the end of or
jimmediately following dialysis. Following the first
idialysis, transient symptoms of muscle twitching, mental
clouding, blurred vision and slurred speech have developed
and spontaneously subsided over several hours (Barber
et al., 1963). Patients have shown unexplained psychotic
i
reactions following initial dialysis with a subsequent
return to normal (Keleman & Kolff, 1960). Symptoms such as
headaches, nausea, vomiting, episodes of disorientation, or !
even grand mal seizures have been seen. Such disturbances j
j
are common during the initial dialysis but occasionally
occur in patients who have had many previously uneventful j
dialyses (Hampers, Doak, Callaghan, Tyler 6c Merrill, 1966).
Patients with hypertension may have an increase in
'blood pressure after the first few hours of dialysis accom-
|panied by headaches, nausea, and vomiting. The pattern may
ipersist for several months and is more common with a coil
dialyzer (Hampers 6 c Schupak, 1967).
The cause of transient symptoms following dialysis
is not clear but may involve the disequilibrium syndrome.
Severe muscle cramps involving the legs and to a lesser
degree the arms have been reported. One patient with a
coil machine who had been on dialysis for four months
experienced severe muscle cramps onsetting six to seven
hours after starting dialysis with gradual fading of
|symptoms in the twelve hours following dialysis (Triger &
jjoekes, 1969). Triger and Joekes proposed that this
I symptom is related to the rate and fall of the plasma
magnesium level and not to an absolute plasma level.
Hampers and Schupak (1967) stated that muscle cramps are
usually due to relative dehydration and responds promptly
to fluid replacement. I
Some dialysis patients, especially in the early
i
phases of treatment, experience the "restless leg syndrome."
This involves uncontrollable restlessness and involuntary j
movements of the legs. The occasional twitching movements
of the legs may not be bothersome to the patient. This
syndrome can be worse the day following dialysis and may
indicate generalized neuromuscular irritability (Hampers &
Schupak, 1967).
Patients tend to feel listless, annoyed, uncomfort-
sable, or depressed the day following dialysis which
I
probably relates to some imbalance (Norton, 1967). Other
transient symptoms following dialysis include: dizziness,
sleepiness, restlessness, cardiac irregularities, hyperten
sion, and hypotension. These postdialysis transient
symptoms do not necessarily coincide with the transient
symptoms experienced during dialysis.
Generally following dialysis the patient experiences
’ ". ~ ................. 27
a return to a state of well-being which lasts for a day or
so until the build-up of toxicity again produces uremic
symptoms. The time when maximum well-being is experienced
jvaries among patients. Most patients feel the best on the
I day following dialysis, but some patients feel the best on
the second day following dialysis.
Following dialysis patients have experienced an
increase in strength and the disappearance of pruritis,
nausea, and muscle cramps (Schribner et al., 1960). The
most striking effect following the initial dialysis is an
i
improvement in mental alertness and concentration; coher
ence markedly increases in the 24 to 72 hours after !
dialysis (Keleman & Kolff, 1960). An increase in mental J
alertness and concentration ability generally follows
regular dialysis.
Chronic Medical Complications
Severe and often chronic medical complications are
I found in hemodialysis patients. These complications
j
!include both reversible and intractable uremic medical
problems and chronic medical problems caused by dialysis.
These symptoms are a source of stress and may
create fatigue, a lessened sense of physical well-being,
and depression. There is less predictability than with
other illnesses about feeling well. This leads to consid-
jerable difficulty for the patient or his family in planning
28;
social comraitments (Wright, Sand & Livingston, 1966). j
Frequent chronic medical complications, the major-
; i
ity to be used as criteria variables in this study, will be
j
!described in the following sections.
j
I Medical Problems of Uremia
Peripheral neuropathy, hypertension, and bone
disease are frequently encountered in long-term patients. j
I
Gastrointestinal bleeding, hypertension, hypotension, J
t
myocardial or congestive heart failure, coronary insuffi- !
ciency, pericarditis, pruritis, anemia, and sexual impo- j
i
tence are uremic complications that can also occur. ,
There is some disagreement as to which of these |
symptoms can be eliminated through proper dialysis. j
Generally with early treatment before terminal uremic
symptoms are markedly severe and by proper medical manage
ment hypertension, hypotension, gastrointestinal bleeding,
and various coronary insufficiencies can be relieved.
lAnemia, peripheral neuropathy, bone disease including
jmetastic calcification, pruritis, and sexual impotence are
i
imedical problems that are not readily changed by hemodialy
sis (Schupak & Merrill, 1965; Sokol et al., 1967).
Schupak and Merrill (1965), however, believed that
;except for anemia, uremic symptoms are related to inade-
I
jquate dialysis and can be improved by increasing the
i
[dialysis time or by using more efficient equipment. They
conceded that pruritis, metastic calcification, and
peripheral neuropathy occur even with controlling the
Iblood-urea nitrogen level and that the mechanism respon
sible for these symptoms are not understood.
|
Hypertension. Many oliguric and anuric patients
become hypertensive during chronic dialysis (Schreiner,
1969). Hypertension may be prevented by establishing and
maintaining adequate blood pressure control through daily
dietary restriction of salt and water (Shaldon, 1968b).
Once hypertension is established it may take weeks of
ultrafiltration and salt depletion to reverse the trend
(Schreiner, 1969).
Hypertension can also be modified through severe
bilateral nephrectomy (Schreiner, 1969). Therefore
patients in this study who have had both kidneys removed
should show a lessened incidence of hypertension than
I patients with intact kidneys.
j
Hypotension. Hypotension is a severe management
iproblem in 4% of the patients with a parallel-plate
jdialyzer and 8% of the patients with a coil dialyzer.
Hypotension is due to excessive ultrafiltration, inadequate
priming of the dialyzer and excessive attempts at salt
j
jdepletion (Schreiner, 1969). Hypotension is also due to
I
Iheart disease and gastrointestinal bleeding.
j
Occasionally in a markedly hypertensive patient
30
during dialysis a slight rise in blood pressure is observed
one half to one hour before a fall to hypotensive levels.
;This occurs just before the patient is dehydrated with
j
jultrafiltration and may be due to generalized vasoconstric
tion resulting from an early fall in circulating volume
(Hampers & Merrill, 1966).
Hypotension is found more frequently in hyperten
sive patients. Hypotensive episodes during or between
i
dialysis can be corrected with increased sodium intake
(Schlotter, 1970). Hypotension during dialysis can be
prevented by slow dialysis to avoid ultrafiltration and by |
discontinuing all antihypertensive medication the day before
dialysis (Hampers & Schupak, 1967). Therefore the occur- j
rence of hypotension in patients indicates improper medical
management.
Gastrointestinal bleeding. Gastrointestinal bleed-
jing, especially peptic ulceration, is found in patients
jundergoing long-term dialysis. Although heparinization has
been implicated along with hypercalemia, the chronic stress
land anxiety may be a major factor (Goldstein, Murphy, Sokol
& Rubini, 1967). Goldstein et al. (1967) found that four
out of seven patients developed peptic ulcers and had a
[markedly elevated basal gastric secretion response in the
jdialysis unit than in the laboratory. They concluded that
jpatients are chosen for stability but have severe
31
psychological problems associated with chronic dialysis.
Patient stress can be reduced by less rigid program demands;
■ and unobtrusive placement of the dialysis machine during j
jdialysis (Goldstein et al., 1967). However, other reports
|indicated that the incidence of peptic ulcer in long-term
;dialysis patients is no greater than the incidence in the
population at large, or about 10% (Hampers & Schupak, 1967).
i
I
Myocardial failure or congestive heart failure.
Many patients beginning long-term dialysis are in frank
congestive heart failure which is due to uncontrollable ;
hypertension and fluid overload (Hampers & Schupak, 1967).
Congestive heart failure is generally reversed by ultra- j
filtration and control of blood pressure (Hampers & Schupakj
j
1967). Congestive heart failure may be found in hyper- j
i
tensive patients in this study who recently joined dialysis.1
But if found in long-term patients the indication would be
of inadequate medical management.
Myocardial failure and especially progressive heart
!enlargement is found in some patients with chronic renal
failure who have been maintained on a selected low protein
diet. Patients with uremic myocardopathy who have been
started on long-term dialysis are prone to cardiac arrhyth
mias and are difficult to manage. Prolonged dialysis has
completely reversed this syndrome but total rehabilitation
may require several months (Hampers & Schupak, 1967).
Patients with myocardial failure prior to dialysis j
may show longer medical difficulties than patients admittedi
to dialysis without this symptom.
I
| Coronary insufficiency. This syndrome involves an
i
insufficient flow of blood to the myocardium which may, in
!
part, derive from a vasoconstriction of the arterial
entrance. Prolonged hypertension can result in aortal
lesions and pulmonary arteriosclerosis which constrict the !
vasculature and reduce blood flow. Coronary insufficiency !
is alleviated through treatment of hypertension or, in rare!
i
circumstances, surgery. The blood flow can also be reduced!
by ventricular premature contractions caused by potassium
intoxication during dialysis in which a rapid shift of
|
potassium occurs in either direction (Hampers & Schupak,
1967).
Pericarditis. Pericarditis is a frequent medical
complication in severe uremia. Dialysis patients with
jpericarditis require more care during dialysis including
I careful regional heparization and monitoring of venous
pressure during dialysis to avoid precipitating hemorrhagic
pericardial tamponade, or compression of the heart from
|profuse bleeding in the pericardium. It is not uncommon in
i
I uremic pericarditis to have pericardial effusion without
I
|tamponade which might be reabsorbed by vigorous dialysis.
!
| Pericarditis can be reversed and prevented with
adequate dialysis (Hampers & Schupak, 1967). Therefore the |
development of pericarditis in long-term patients may |
indicate inadequate number of dialysis hours per week.
! Anemia. Anemia is the most intractable uremic
j
; symptom. Even when the pruritis and neuropathy of inade
quate dialysis are reversed, anemia lingers on (Hampers &
Schupak, 1967). Patients with chronic renal failure have
decreased red blood cell production and red blood cell
survival. The cause of anemia in chronic uremia is unknown J
and rapid improvement occurs with a kidney transplant even ;
I
if anemia was present in long-term patients (Sokol et al., j
1967). |
I
Anemia presents as weakness and easy fatigability j
(Gonzalez, Pabico, Brown, Maher & Schreiner, 1963). Most
chronic hemodialysis patients require continued red cell
replacement which is obtained through transfusions of
jpacked red cells (Hampers & Merrill, 1966). Patients vary
|in their need of red cell replacement which can range from
jfour transfusions per week to no transfusions over months
!
| (Gonzalez et al., 1963; Hampers & Schupak, 1967). The
I
average need for red cell replacement is two units per
patient per month (Hampers & Schupak, 1967). Anemia can
also be reduced by raising the hemoglobin with intravenous
administration of iron (Shaldon, 1968b). However, the
jincorporation of administered iron in the viable red cells
34
is decreased in uremic patients who have anemia (Hampers & j
Schupak, 1967). I
Lindholm, Pace, and Ressell (1969) found that by
I increasing the amount and frequency of dialysis treatment,
I
anemia of uremia could be controlled to a hematocrit level
of 20% reducing blood transfusions. They were studying the
possibility of reversal of anemia by more vigorous dialysis
treatment.
Patients with severe anemia would probably experi- |
ence more fatigue which could affect rehabilitation.
i
Anemic patients receiving more frequent transfusions would j
be more susceptible to transfusion complications such as
hepatitis or iron overload. Iron overload can result in j
hemosiderosis (Sokol et al., 1967). ;
Metabolic bone disease. Metabolic bone disease is
common in patients who have been maintained on dialysis
longer than two years. In Seattle 11 out of 26 patients
|dialyzed longer than two years had some evidence of bone
disease. The occurrence of metabolic bone disease in long
term dialysis patients is insidious and generally asympto
matic early in its course. Severe bony abnormalities
result. In advanced stages diffuse demineralization of
bones, observable by X-ray, results in pathological frac
tures especially in the ribs (Hampers & Schupak, 1967).
j
iConsiderable progression of bone demineralization has been
observed over a one-year period (Gonzalez et al. , 1963).
;A primary cause of metabolic bone disease in chronic renal |
failure is the defective calcium absorption from the gut
!
|(Hampers & Schupak, 1967). Calcium becomes bound with
phosphorus into an insoluble complex in the gastrointes
tinal tract. Secondary hyperparathyroidism or "pseudo-
gout" is often in long-term dialysis patients and occurs
from diffuse hypertrophy of the parathyroid glands as a j
result of high phosphorus and low calcium levels. j
Increased frequency of dialysis and greater residual kidney!
function are two factors decreasing the likelihood of j
pseudo-gout and calcium phosphorus binding (Lindholm et |
al., 1969). |
Where calcium absorption is markedly impaired for
long periods, frank osteomalacia, or "renal rickets," may
occur; but this symptom is not common. To prevent bone
disease aluminum hydroxide gels can be administered daily
I to bind phosphorus and lower the serum phosphorus level
(Hampers & Schupak, 1967). Since patients with renal
I
I
;failure develop a resistance to vitamin D, high doses of
vitamin D as well as calcium are administered to dialysis
patients who develop bone changes (Hampers & Schupak,
1967).
| Calcium abnormalities also include metastic calci-
fication in tissues, the collection of calcium phosphorus
nodules in joints, and calcification of blood vessels
; '...' ..................... 36
(Schreiner & Maher, 1961). Patients with soft tissue
i
calcifications prior to dialysis may show complete resorp- i
;tion of calcium deposits within one to six months following
| |
jdialysis; however, calcification of blood vessels may not
resolve even with intensive dialysis (Hampers & Schupak,
1967).
The mechanics of calcification are unclear and may
be due to high calcium concentration in the water used for
dialysis or by secondary hyperparathyroidism (Schreiner & |
Maher, 1961). Occasionally the parathyroid glands are
removed where hyperthyroidism is certain and the patient is j
symptomatic (Hampers & Schupak, 1967). However, it is felt:
that adequate dialysis prevents renal osteodystrophy, j
i
pseudo-gout and metastic calcification (Shaldon, 1968b).
Sleep problems. Many uremia and dialysis patients
have trouble falling asleep or in waking at frequent
intervals throughout the night. Although a heavy psycho
logical overlay probably occurs with insomnia, the major
factor is inadequate dialysis. More frequent and intensive
j dialysis over several weeks or increasing the hematocrit
can improve the sleep pattern (Hampers & Schupak, 1967).
Pruritis. Pruritis, or itching skin, is a
frequently observed neurological complication in long-term
jhemodialysis patients. The mechanism of pruritis is
|
! unknown but the effect of retained metabolites on peripheral
!nerve endings has been implicated since relief or diminution'
j i
of symptoms can occur by increasing the number of dialysis
I
hours. However, some patients show no improvement with I
jincr eased dialysis which may indicate that either dialysis
remains inadequate or a cause other than retention of !
metabolites was responsible (Hampers & Schupak, 1967).
; i
Pruritis might be due, in part, to hyperparathyroidism.
j The intensity of pruritis may vary among patients
|from mildly annoying to unbearable. A functional basis for j
i ;
pruritis in older patients has been proposed (Gonzalez et |
jal., 1963). Medications such as antipruritic lotions, i
jantihistiminics, or analgesics are of limited value in
alleviating pruritis (Hampers & Schupak, 1967). Satina ;
j i
baths taken daily except for the day of dialysis have been
i i
reported effective in treating uremic pruritis (Snyder &
Merrill, 1966). However, Hampers and Schupak (1967) felt
that relief from sauna baths is short-lived and of limited
i
value and that the only treatment which gives satisfactory
results is increased intensity of dialysis.
Pruritis is expected to be found in patients in |
this study and may relate to the number of hours of dialysis!
per week. j
!
| j
| Peripheral neuropathy. Peripheral neuropathy is a
pommon medical complication of long-term dialysis patients I
(Hampers & Schupak, 1967; Tyler, 1965). The lower j
38;
extremities are commonly involved although some severe
cases show upper extremity involvement. Peripheral
neuropathy includes: pain and parasthenia, hypersensitiv-
i
ity to touch, a burning sensation called the "burning foot
I
jsyndrome," loss of deep tendon reflexes, and muscle waste
(Hampers & Schupak, 1967; Schreiner, 1969; Sokol et al.,
1967).
Neuropathy has developed in patients from 19 to 65 j
I
years of age. However, one study found a lower incidence
of sensory motor neuritis in females (Tyler, 1965).
I
The onset of peripheral neuropathy may be sudden or;
gradual. It may initially present as mild tingling and
numbness of the hands and feet. Pain is the major symptom j
i
and may be incapacitatingly severe. Although patients
i
complain mainly of the sensory manifestations of the
disease, a significant motor component may be present and
paralysis can develop with minimal sensory manifestations.
;Motor weakness can be severe and progress from mild "foot
;drop" to total paralysis of the extremities (Hampers &
Schupak, 1967).
The pathology of peripheral neuropathy involves
extensive demyelination of the distal portion of the
peripheral nerves. The etiology is unknown and secondary
to uremia. However, the development may be possibly due to
incomplete metabolism of vitamins resulting in a deficit at
i
;the tissue level or due to deranged carbohydrate metabolism
39 !
(Hampers & Schupak, 1967). Neuropathy has also been
attributed to insufficient dialysis or an accumulation of
;dialyzable metabolites (Hegstrom et al., 1962).
i With increased and more efficient dialysis,
;neuropathy can be prevented or reversed in dialysis
|patients (Eschbach et al., 1957; Hampers & Schupak, 1967;
Schupak & Merrill, 1965; Schupak, Sullivan & Lee, 1967;
Tenchkoff, Jebsen & Honet, 1967). Once damage has occurred!
in the motor nerves reversibility is slow at best and only
arrestment may be possible (Hampers & Schupak, 1967). One !
totally incapacitated patient showed no change after one
year of vigorous dialysis treatment (Schupak et al., 1967).
However, the disappearance of motor neuropathy has been
reported in one patient (Eschbach et al., 1967). In one
study, "foot drop" which developed after four months of j
dialysis completely disappeared with a 50% increase in
dialysis time (Schupak et al., 1967).
Peripheral neuropathy occasionally results in
decreased nerve conduction time (Curtis et al., 1969).
However, diminished nerve conduction rates are found in
many long-term dialysis patients who have no clinical
evidence of neuropathy (Hampers & Schupak, 1967). However,
deterioration in nerve conduction velocities is the most
|serious indicator and most dangerous manifestation of
|inadequate dialysis (Rae, Marr, Steury, Gothberg &
i
jDavidson, 1968).
: ........................ " 40 i
j
Hemodialysis before the onset of neuropathy
prevents its occurrence (Techkoff et al., 1967). The I
idevelopment or progression of neuropathy following dialysis
i
lonset indicates inadequacy of dialysis (Hampers & Schupak,
I
'1967; Schupak & Merrill, 1965; Techkoff et al., 1967).
Eschbach et al. (1967) reported that three out of four of
their first patients developed motor neuropathy but that no
neuropathy has developed since the duration of dialysis was j
i
increased from eight to ten hours three times per week.
Peripheral neuropathy is expected to be found in
some patients in this study. It may be related to sympto- j
mology before dialysis onset and to length of dialysis time.;
It may be found to interfere with job rehabilitation.
s
Sexual problems. Loss of libido and impotence are
common complications in long-term male hemodialysis
patients (Schreiner, 1969). The loss of libido generally
Ibegins around the time of appearance of clinical uremia
symptoms prior to dialysis (Elstein, Smith 6c Curtis, 1969;
i
jSchmitt, Shehadeh 6c Sawin, 1968).
I
The loss of libido may be related to patients feel
ing too ill, tired or preoccupied (Elstein et al., 1969).
Dialysis patients have been reported to initially curtail
I sexual activity for fear of damage to their shunts; this
jfear was overcome in time (Curtis et al., 1969). However,
jail autopsied males in one study had a marked atrophy of
: ’ ’ .’ ....' ..... . 41
germinal epithelium in the testes (Elstein et al. , 1969).
Male hemodialysis patients may show an arrested or abnor- |
; mally low spermatazoa (Elstein et al., 1969; Sokol et al.,
j 1967).
Sterility and sexual impotence frequently are not
i improved by intermittent hemodialysis and may persist
despite a feeling of well-being and apparent metabolic
equilibrium. The testicular atrophy and tubular hyaliniza-j
tion in chronic uremia is not likely to be improved by
chronic dialysis (Sokol et al., 1967).
Fertility is also reduced in dialysis patients
i
independent of impotency (Sokol et al., 1967). It is j
unknown if the infertility is due to specific effects of j
uremia or to the chronic ill health accompanying uremia j
(Elstein et al., 1969). However, no female dialysis
patient has become pregnant following dialysis (Schreiner,
;1969).
The incidence of impotence and fertility in male
I patients varies among treatment center. Goodey and Kelley
(1967) reported a normal rate of sexual activity in two out
of fourteen patients. Male patients have denied sexual
problems or sexuality aversely affected by maintenance
dialysis (Curtis et al., 1969).
I Elstein et al. (1969) found regular sexual activity
|in 17 out of 35 patients. Furthermore, ten male patients
remained potentially fertile and three of these patients
42
under 30 years of age were able to impregnate their wives
■ even though their semen analyses were subnormal. Their
parentage was supported by blood group studies. Elstein
concluded that it is no longer justifiable to assume that
i the infertility and impotence of the uremic state continues
!following maintenance dialysis. Elstein found in most
cases a libido returning to the preill-health level.
Patients regard sexual potency as a part of their return to;
normal life (Elstein et al., 1969).
Other sexual complications can occur in uremic
i
patients. Amenorrhea is common in women patients
(Schreiner & Maher, 1965). Young girls on dialysis have an|
absence or retardation of sexual development and menarche j
(Schreiner, 1969).
I
Transient gynocomastia has been observed in male
;patients which presents similarly to the enlarged mammalary
gland development seen in refeeding of malnourished males
following World War II (Freeman, Lawton & Fearing, 1968;
|Schmitt et al., 1968). Of the 10 out of 24 dialysis
|patients with gynocomastia, nine developed enlarged breasts
two to nine months after two times per week dialysis while
one had symptoms before dialysis. In another sample six
|out of seven male patients exhibited gynocomastia and all
|had the following symptoms: tenderness of the breasts,
j
| poor sexual function, and small testes or poor spermatazoa
|(Schmitt et al., 1968). The mechanism of gynocomastia is
! 43 !
| i
IUnknown but may be due to secretion of an estrogen by the |
! i
itestes (Schmitt et al., 1968). It is reversible.
; Impotence and total sexual inactivity is expected
to be found in some patients in this study. The impotence
found may correlate with shifted attitudes toward the
spouse following dialysis or with patient well-being. The
'attitude of the treatment center regarding sexual expecta
tions of dialysis patients may also affect patients1
j i
jattitudes and expectations . j
i I
' i
Medical Problems Caused by Dialysis Treatment '
! Hepatitis, or inflammation of the liver, is a com
plication of frequent blood transfusions or of inadequate i
, i
sterilization of syringes and needles (Sokol et al., 1967).
Hemosiderosis, or iron overload, can result from an |
excess of iron obtained through transfusions (Sokol et al.,
1967).
i
: i
Bleeding problems can occur through rebound anti- |
Coagulation following rigid heparin administration during
dialysis to prevent clotting. This increases the risk of
bleeding in dialysis patients and the risk of hemorrhage at |
the shunt site (Hampers & Schupak, 1967; Sokol et al., |
1967). Evidence suggests that chronic hemodialysis patients I
i |
have a higher mean value for clotting than a nonuremic, |
! I
nondialysis, random population sample, which then con-
| j
tributes to clotting of the cannula (Erickson, Williman &
IPendras, 1966). Some patients in a hypercoagulable state
irequire anticoagulants such as Coumadin to prevent repeated
^clotting of shunts (Hampers & Schupak, 1967).
CHAPTER III
i
i
! LITERATURE REVIEW OF HOME HEMODIALYSIS:
I
| PHYSICAL ASPECTS
i
j
|Background and Advantages
I of Home Dialysis
Hemodialysis as a home treatment was devised at
I
Seattle in 1964 when a lack of space on the dialysis
program for a bright 16-year-old girl necessitated training!
her highly motivated and intelligent parents to operate the;
machine in their basement (Eschbach et al., 1967). ;
Patients are now dialyzed in their own bedrooms using
regular beds (Eschbach et al., 1967).
A survey covering 78% of the estimated dialysis
centers and 81% of the estimated dialysis patients dis-
i
closed that in 1967 of the 850 or so dialysis patients in
I the United States, about 112 were on home dialysis (Katz &
Procter, 1969). In 1967, then, hemodialysis was primarily
performed at a center. Although one-third or so of the
centers had home dialysis patients, half of these centers
had two or less home patients (Katz & Procter, 1969).
Today more patients are still being dialyzed in a
!
center but the percentage of home patients is increasing
46
since home dialysis is a preferred method of treatment for
chronic uremia. Though initially stressful, the isolation
land independence of home dialysis has medical, bacteriolog
ical, and psychological advantages for both the patient and
i
jthe family (Wright et al., 1969). The bacteriological
advantage of home dialysis is the reduction of transmission
of infectious hepatitis (Nabarro, 1967). j
I
A major medical advantage to the hospital unit is j
that home hemodialysis offers the greatest possibility for '
survival for patients dying of terminal renal failure
(Esmond, Strauch, Zapata & Hernandez, 1967). Patients on
home hemodialysis do not block a hospital bed (British |
i
Medical Journal, 1967). If centers which dialyze a patient;
I
twice weekly in the unit are converted to training centers i
for home hemodialysis, then one hospital based hemodialysis
bed can handle over 10 times the present number of individ
ual patients (Esmond et al., 1967).
| Medically, home dialysis is superior because more
i
!intense and frequent dialysis is possible which allows
I better control of the azotemic state and less need for
i
!
I
|transfusions (Eschbach et al., 1967). Patients trained to
dialyze overnight three times per week while sleeping
enjoyed a greater sense of well-being, had more stamina,
and had a virtual disappearance of uremic medical complica-
I
tions other than anemia (Eschbach et al., 1967).
Patients on home dialysis have had fewer
47 |
complications and fewer unscheduled hospital admissions than
those treated regularly in the hospital (Johnson, Hathaway, !
'Anderson & Carlson, 1970).
| Home hemodialysis has psychological advantages.
[Home dialysis allows the patient more freedom and less
jtraveling time to a center (Davidson & Pendras, 1967).
Unattended nighttime home dialysis can be easily integrated
i
into the ordinary household schedule thereby preserving the !
normal family unit (Eschbach et al., 1967). Home dialysis I
allows more flexibility in daily life (Fellows, 1966).
Home dialysis allows the patient to be more independent and '
self-sufficient. There is less dependency on the hospital j
unit (Fellows, 1966). |
The financial advantage of home dialysis is that it j
i
is less expensive than center dialysis. Initial costs
including purchase of equipment, training, and house
^remodeling run between $10,000 and $14,000 while annual
costs thereafter for supplies, medical services, and equip
ment repair average around $3,500 (Eschbach et al., 1967).
j
Home dialysis will always be less than half the cost of
dialysis in a center (Eschbach et al., 1967).
Home Training
|
Patients are trained at a center for future home
!
dialysis. Centers vary in the amount of training time
j
[before patients are released to dialyze on their own.
48
A full two months of training is advisable if the transi
tion to the home is to occur with a minimum of emotional j
strain on the patient and family (Eschbach et al., 1967).
;Furthermore, it takes from three to six weeks to get the
|patient in a good physical condition where the uremic
symptoms are corrected and the blood pressure is lowered to
normal (Eschbach et al. , 1967; Rae ScMarr, 1969).
Initially patients' spouses were taught to do the
dialysis, but this frequently created psychological prob- |
lems for both the patient and the spouse. Immature !
patients not trained to be primarily responsible for
dialysis have become too dependent on their wives with muchj
i
resulting hostility and denial which made it difficult for j
the wives to cope with these added stresses and burdens j
!
which threatened family stability (Eschbach et al., 1967).
Self-operation is the choice of physicians to resolve the
problem of guilt feelings if a lethal mishap occurs
(Tsaltas, 1967). Self-operation minimizes dependency and
j eases the stress found by other family members (Eschbach
!et al., 1967).
Some center-treated patients have refused to go on
I
a home program (Childs, Ogg Sc Cameron, 1969; Smith, Curtis,
McDonald Sc de Wardener, 1969). Their refusal is generally
based on an overdependency on the hospitalized unit. To
circumvent overdependency on the unit many centers admit
patients to maintenance dialysis only if they agree before
treatment is begun to the possibility of future home
dialysis (Davidson & Pendras, 1967).
Although the preferable treatment form, not all
patients are suitable for home dialysis. Any medical
i
j condition requiring nursing supervision eliminates home
; dialysis (Davidson Sc Pendras, 1967). Patients without a
home would be unsuitable for a home program. Some patients
are slow to learn or have a slow return of their mental j
facilities (Smith et al., 1969). Some patients lack the !
I
intelligence or independence necessary to learn home
j
dialysis with our present techniques (Davidson Sc Pendras,
1967). However, lack of intelligence has been compensated !
for by motivation and thorough dialysis training (Eschbach [
et al., 1967). Patients with excessive denial who are late
to instruction,have a "don't care" attitude, frustrate
training plans, or show unreliable behavior would be
unsuitable for a home program (Smith et al., 1969). The
dependent, immature patient will be attracted to center
i
j dialysis because of the emotional security of being able to
I
I
Srely on a nurse-technician team for his dialysis (Eschbach,
Wilson, Peoples, Wakefield, Babb & Schribner, 1966).
Although this study will only include patients who
!
[reside near the treatment centers, proximity to a center is
I
[not necessary for a home program. Initially it was
|believed that one condition for home dialysis was that the
i
[patient live near the center (Nabarro, 1967). However,____
50
m any c e n t e r s r e p o r t s u c c e s s f u l hom e d i a l y s i s o f p a t i e n t s
l i v i n g h u n d r e d s o f m i l e s aw ay w ho r e l y o n t h e l o c a l m e d i c a l I
c o m m u n ity f o r t h e i r n e e d s f o l l o w i n g t r a i n i n g ( E s c h b a c h
e t a l . , 1967; D a v id s o n & P e n d r a s , 1967; R ae e t a l . , 1968;
W ood, 1969). F u r t h e r m o r e , hom e p a t i e n t s i n r e m o te a r e a s
j w ho a r e f o r c e d t o b e m o re in d e p e n d e n t m ake f e w e r c a l l s t o
t h e t e c h n i c i a n s r e g a r d i n g t h e e q u ip m e n t (R a e e t a l . , 1968).
H o w e v e r , hom e p a t i e n t s l i v i n g i n r e m o t e a r e a s a r e t r a i n e d
f o r in d e p e n d e n c e b y b e i n g r e s p o n s i b l e f o r d i a l y s i s o p e r a
t i o n , d i e t , an d t h e d e t e r m i n a t i o n a n d a d m i n i s t r a t i o n o f
t r a n s f u s i o n s (R a e e t a l . , 1968).
|
P r e d i c t o r V a r i a b l e s R e l a t e d t o j
D i a l y s i s S c h e d u le a n d T r a i n i n g
j
N um ber o f t r a i n i n g h o u r s a n d s e l f - o p e r a t i o n a r e tw o j
p r e d i c t o r v a r i a b l e s o f p a t i e n t a d a p t a t i o n t o b e u s e d i n
t h i s s t u d y . T h o r o u g h t r a i n i n g w i t h e m p h a s is on s e l f -
i d i a l y s i s h a s b e e n s t a t e d a s o n e m a jo r f a c t o r c o n t r i b u t i n g
| t o s u c c e s s f u l p s y c h o l o g i c a l r e h a b i l i t a t i o n o f t h e hom e
|
patient (Eschbach et al., 1967). At this point it is
unknown if significant differences occur in type of train
ing of the centers to be used in this study which could
affect patient adaptation. However, an effort will be made
to determine if total number of training hours correlates
with aspects of adaptation or rehabilitation. Some home
ipatients in this study do not take self-responsibility for
dialysis. It may be found that they are more dependent in
nature and less prone to rehabilitate.
; Whether or not the patient sleeps during dialysis
will also be used as a predictor variable in this study.
!
;Some centers train the patient to sleep during dialysis
(Eschbach et al., 1966). Sleeping during dialysis would
allow overnight dialysis of up to 10 hours three times a
week which would enable a maximal correction of uremic
I
symptoms and a lessened incidence of medical complications. j
Overnight dialysis would also prevent dialysis from inter
fering with employment hours. Whether sleeping during
dialysis results in lessened medical complications or an
improved life style remains to be seen. j
Number of times of dialysis per week and hours of |
dialysis weekly will be predictor variables in this study.
Frequency of dialysis is more important than total hours
since frequent dialysis prevents large changes in fluid,
lelectrolyte, and nonprotein nitrogen levels (Rae et al.,
!
! 1968). Centers advocate three dialyses per week for home
[patients (Davidson & Pendras, 1967). Center dialysis is
[generally limited to two times per week only for practical
and economic reasons. With two times per week dialysis more
complications such as fatigue, nausea, and headaches are
i
jfound during and after dialysis (Rae et al., 1968). More
i
jtransient medical symptoms should occur for patients who
[dialyze less frequently.
Patient Involvement
Once the patient has completed training and j
dialyzes at home, he is responsible for various aspects of
his treatment. His cooperation with treatment primarily
i involves dietary adherence and cannula care as well as
i
dialysis administration. Dietary adherence and cannula
complications will be included as criterion variables in
this study.
Besides the time involved in actual dialysis, the j
i
patient and his family must assume a considerable work |
i
load. Often 10 to 12 hours per week are required to cycle
!
the dialyzer, care for the cannulas, and maintain and check j
equipment (Curtis, Cole, Fellows, Tyler & Schribner, 1965).'
Declotting procedures, postcannulation care, and simple j
laboratory tests are an additional family burden (Curtis
et al., 1965). Patients may also store blood in home
refrigerators for self-administration of transfusions when
necessary.
i
; Dietary adherence. Normal kidney function continu-
i
i ously balances body plasma to prevent medical complications
j
!from excessive ingestion of food substances or fluid,
j Since a kidney machine is less efficient and only a
I
iperiodic treatment, adherence to diet is more critical in
i
I
|hemodialysis for avoiding life-risking complications than
I
|any other medical condition. In hemodialysis dietary and
jfluid restrictions are necessary to maximally control______
r~ .. ... ........ .~ ’ ...... ’ 53 |
hypertension, the electrolyte balance, and weight gain ;
(Abram & Wadlington, 1968). |
Some proposed diets for dialysis patients restrict
jprotein (Schupak & Merrill, 1965; Shaldon, 1968b; Shaw
|
let al., 1965). Others do not (Lindholm, Burnell & Murray,
i
11963; Hampers & Schupak, 1967; Thomson, Waterhouse,
MacDonald & Friedman, 1967).
There is a trend towards liberalizing protein
intake. Schupak et al. (1967) were not convinced that a !
j
severe protein restriction was good, but that it may be
harmful. Recent research indicates that for twice weekly j
dialysis, a diet containing at least 35 cal/kg and .8 to .9 |
i
gm/kg of protein of which .63 gm/kg is of high biological
value is most effective in reducing uremic symptoms (Kopple,|
Shinaberger, Coburn, Sorensen & Rubini, 1969).
However, all diets restrict sodium and water intake
since excessive fluid intake can cause hypertension.
iSodium intake must be restricted since sodium indirectly
influences fluid retention through its influence on the
I
Ithirst mechanism (Hampers & Schupak, 1967).
; Good patient cooperation in dietary sodium restric
tion is necessary since the overall average level of total
sodium is more critical for hypertension than the temporary
restoration of lower body sodium following each dialysis
(Lindholm et al., 1963). There is a trend towards liberal
izing the diet and imposing rigid sodium restrictions only
on patients with hypertensive problems (Schupak et al., j
1967). Patients who deviate from a low sodium diet learn j
; by experience how much they can deviate without developing
| severe hypertension (Lindholm et al., 1963).
! Rigid control of fluid intake is necessary since
!even small increments in plasma volume may significantly
I alter blood pressure. Furthermore, removing great amounts
of excess fluid during dialysis can result in postdialysis
j
fatigue and a "washed out" feeling (Hampers & Schupak,
1967). The anuric patient is generally restricted to a
maximum fluid intake of 500-800 ml. of drinking fluid per ;
day which keeps the weight gain under one pound per day i
between dialyses (Schupak & Merrill, 1965; Hampers & i
Schupak, 1967).
Most dialysis patients are required to make a total
readjustment from previous eating habits (Hampers &
Schupak, 1967). Home dialysis allows greater dietary
;flexibility than inpatient dialysis since the home patient
!can increase the length of dialysis time to compensate for
a more nutritious higher protein diet or for a near future
jsocial event of eating or drinking.
Patients with an acute renal failure have more
difficulty adjusting to the diet than patients with a
chronic renal problem (Curtis et al., 1969). The adjust
ment to the diet depends on the patient's stability but
even the most stable patients occasionally need to rebel
and have a large meal. For some patients the resentment
over restrictions due to the illness is projected to the
[diet. However, the irksome, monotonous diet is accepted
(gradually by the majority of patients (Curtis et al.,
|1969).
Patients vary in their cooperativeness with dietary
restrictions. A survey covering 93 (78%) of the dialysis
centers and 611 (81%) of the estimated dialysis patients in
the United States in 1967 disclosed that one-third of the
!
patients failed to cooperate with aspects of the dialysis
regime. Adherence to dietary restrictions of salt, water, ;
or protein intake was the most frequent problem area and
accounted for 59% of the total noncooperation with treat- j
ment regime (Katz & Procter, 1969). |
Some patients repeatedly go off their diets and
! create potentially fatal complications. Excessive sodium
intake is a major dietary indiscretion which can result in
i a seven to ten pound weight gain between dialyses (Schupak
let al., 1967). Food binges or food kleptomania have been
[reported in dialysis patients. One patient with an author-
; ity problem went on a food orgy which resulted in severe
j excess potassium, cardiac arrest, and death (Rubini &
| Goldman, 1968).
; Dietary indiscretion is a dramatic avenue of acting
out conflictual feelings toward dialysis which, at times,
! can reach giving in to conscious or tinconscious death
r ~ ~ ' ~ ' ” ” ~ 5 6
impulses (Abram 6c Wadlington, 1968). Psychological factors
including massive resistance, self-destructiveness, or |
^authority conflicts may play some role in habitual lack of
jdietary self-control (Schreiner 6c Maher, 1961). Extreme
; denial or dependency conflicts could also be involved.
Dietary criterion variable. Stability of weight
loss during dialysis is a major indicator of dietary
|
adherence. A weight gain between dialyses in excess of one :
kilogram indicates dietary indiscretions. This study will
use the total frequency within the last three months of ,
weight gain between dialyses in excess of one kilogram as
an indicator of dietary adherence. j
This measure will be obtained primarily from the j
i
patient's log. Home patients maintain a dialysis log which j
includes such information as pre-and postdialysis blood j
pressure and weight, duration of dialysis, and weekly hemato-
;crit (Eschbach et al., 1967). Some patients in this study
iare expected to show repeated dietary indiscretions which
could increase the incidence of hypertension and other
medical problems.
Cannula care. The life expectancy of patients is
'dependent on the maintenance of a functioning cannula (Brand
I
j
6c Komorita, 1966). Therefore, along with self-control in
I
idietary regulation the patient must carefully protect the
i
shunt site. Physical activities which could jar the shunt
site must be avoided. The patient must properly clean the j
; shunt site to avoid infection. Daily cleaning of the |
; cannula is recommended (Brand & Komorita, 1966; Quinton,
| Dillard, Cole & Schribner, 1962). Patient cooperation with
| shunt care varies from meticulous daily washing and chang-
; ing of the dressing to changing the dressing only when
soiled (Brand & Komorita, 1966).
Cannula survival. The average length of survival
of arterial and venous cannulas varies from unit to unit. I
Early publications report cannula survival under two months!
(Gonzalez et al., 1963; Ramirez, Swartz, Onesti, Mallioux &
Brest, 1966). Average cannula survival of about six months!
has been frequently reported (Hegstrom et al., 1961; j
Hendler et al., 1967; Schupak et al., 1967; Shapiro,
Messner & Smith, 1968). Other published survival rates
average 11 to 17 months for the arterial cannula and 10 to
12 months for the venous cannula (Curtis et al., 1969;
| Murray, Pendras, Lindholm & Erickson, 1964; Pendras &
i Smith, 1966; Sokol et al., 1967).
[
The arterial cannula generally lasts about three
months longer than the venous cannula. However, in one
report the average arterial cannula life of 17 months
| exceeded the average venous rate by seven months (Curtis
et al., 1969).
| For home dialysis patients, one study covering
5 8 !
eight patients from 1964 to 1966 reported an average
arterial cannula life of 6.6 months and the average venous
icannula life at five months (Eschbach et al., 1966). In
I
) 1967 the same center reported an average cannula life of
inine months arterial and six months venous for home dialysis
'patients (Eschbach et al., 1967).
There are individual patient differences in these
averages. One patient has had an arterial cannula for 18 !
months and a venous cannula for over 21 months (Sokol
et al., 1967). Cannula survival has been longer for
patients who have been on dialysis over a year with aver
ages of 21 months arterial and 13.6 months venous (Curtis i
et al., 1969). Long-term dialysis patients have learned
how to protect the cannulated limb during sleep to avoid |
i
separations or kinking which might result in clotting. |
They also have learned proper cleansing care to avoid
infections. Furthermore, care given to the cannula in the
|first three weeks following implantation is critical to
'the cannula life and immobilization and careful cleaning of
jthe cannulated limb is necessary (Quinton et al., 1962).
j
Variables affecting the life of a cannula include:
type of equipment, personnel turnover, technique differ
ences, long-term objectives, and patient intelligence and
cooperation (Hampers & Schupak, 1967, p. 64). However, one
patient with an intelligence quotient of only 85 had only
jone arterial and two venous relocations with no infections
59.
; over 17 months (Schupak et al., 1967). Therefore, coopera-j
j
tion may be more crucial than intelligence. Silastic- j
I teflon shunts have a longer survival rate than teflon
i
| shunts (Quinton et al., 1962).
i
A recent innovation in shunt procedure is the veni-
| puncture technique in which a direct arteriovenous fistula
is made between a nearby artery and vein in the arm by
puncturing the vessels directly with two large bore needles
(Schreiner, 1969). This method of attachment to the
machine relieves the daily cannula care and increases the 1
i
t
flexible motion and activities for the arm (Schreiner, |
1969). |
Two major complications associated with the shunt
are spontaneous clot formation within the shunt and infec
tion at either the exit sites or along the suture line
(Goodwin, Castronuovo & Friedman, 1969). Clotting and
infections are serious since cannula failure can result in
;a need to relocate the shunt. Cannulas are also subject to
I
I
!hemorrhage from disengagement or accidental cutting of the
line.
Cannula infection. The shunt site is a major
source of infection which makes cleanliness of the cannulas
important (Brand & Komorita, 1966). The care of the
cannula includes: cleaning the exit sites, cleaning the
entire limb, changing the dressing daily, and observing for
kinks in the joint or slippage of the rings that hold the
j
| joint together (Fellows, 1966).
Patients vary in their frequency of shunt infec-
; tions. Inadequate or delayed antibiotic therapy for shunt
infections can result in phlebitis, septicema, or irrevers-
I
i ible clotting of the shunt with loss of function (Goodwin
! et al., 1969).
I
Hemorrhage and disengagement. Every shunt is a
potential source of lethal hemorrhage as the blood flow
I during dialysis is 200-300 ml/min (Sokol et al., 1967).
| Leakage or disruption may result in severe blood loss.
j
j After the shunt insertion, oozing at one or both of the
;cannula incisions frequently occurs the first few times
I dialysis is carried out; but it is rarely significant and
ican be controlled with local pressure. Fibrin formation
'around the cannulated vessel usually stops the oozing in
several weeks (Sokol et al., 1967).
Hemorrhage can result from disengagement of the
:shunt. Home hemodialysis patients have had cannula connec-
Itions separate during the night dialysis while sleeping,
j
|but a monitor alarm awakens the patient immediately
!(Eschbach et al., 1967). Although separations are infre-
|quent during active hours, patients have been instructed to
I
|carry cannula clamps so that if the shunt comes apart it
can be clamped immediately. Patients exhibit anxiety over
I shunt injury. One patient was reported to carry two |
i
j tourniquets on his person following a shunt separation
: while shopping (Brand & Komorita, 1966).
Accidents to the shunt occasionally occur and
I
! result in hemorrhage. The silastic shunt has been cut by
i :
! patients while changing the dressing (Shapiro et al.,
1968) . On one occasion a resident punctured the shunt |
| while drawing a blood sample (Nakamoto, Brandon, Franklin, j
| Rosenbaum & Kolff, 1961). I
j i
| Patients have injured their shunt purposefully.
| .
| Confused patients have cut the cannulas with a manicure
i i
| scissors, or directly disconnected the cannula (Nakamoto
! et al., 1961). Shunt accidents are a dramatic avenue of
acting out conflictual feelings towards dialysis or of
giving in to conscious or unconscious death impulses
; (Abram, 1969a). In one case an accident-prone patient with1
, a history of stealing sharp surgical instruments from the
dialysis unit had a sixth and fatal disconnect within eight
months (Retan & Lewis, 1966).
, Clotting. Clotting of the cannula is a most common!
| medical problem which is usually associated with segmental
I narrowing of the cannulated vein (Eschbach et al., 1967).
' Clotting is liable to occur when the cannula blood flow j
| during dialysis falls below 125 ml/min (Eschbach et al., j
1967). Cannula clotting is serious since it can result in
62 !
infection or the need of a new cannula if the vessel cannot ;
be opened (Fellows, 1966; Sokol et al., 1967). Declotting '
of a venous cannula carries the risk of pulmonary embolism
Isince declotting involves pushing the clot into the venous
circulation (Sokol et al., 1967).
! Cannula clotting has also been attributed to expo
sure to cold or outside pressure, defective surgical
j
positioning, and malrotation or unusual activity (Curtis !
i
I
et al., 1969; Quinton et al., 1962). Another cause of
clotting is the tendency to overguard the cannulated arm
instead of using it for certain activities (Brand & I
i
i
Komorita, 1966). Straining or lying on the shunt can j
result in a clot at the juncture site with the artery or j
vein (Curtis, 1968). Blood clotting has occurred during j
overnight dialysis when the venous line became kinked and
occluded, heparin pumps malfunctioned, or a patient over
slept and failed to self-administer heparin (Eschbach
let al. , 1967) .
j If a clot develops the cannula is washed out with
jwarmed, heparinized normal saline. After the cannula
clears, the artery and vein are irrigated with the solution.
The shunt is reconnected and the flow resumed.
Clotting occurrences vary among units. In 1962 one
study reported clotting average time of one month with a
range of 3 to 160 days (Nakamota, 1962). More studies
reported a clotting average time of once per six months
(Curtis et al., 1969; Hegstrom et al., 1962). One patient
had 10 clots within seven months (Hegstrom et al., 1962).
iAnother patient had six clots, three infections, and three
relocations over 13 months which was considerably higher
:than the average incidence of the reporting unit (Murray
jet al., 1964).
Shunt Criteria Variables
This study will record the incidence of shunt
clots, infections, relocations, and disengagements over the
past three months as criteria variables of cooperation with
[treatment and of adaptation. Average incidence of clots or
!infections or of cannula life, although beneficial informa-
jtion, will not be available in this cross-sectional study.
If previous findings are correct, patients on the
^program over one year should show a lessened incidence of
ishunt complications. Disengagements can be regarded as
Ipotential suicidal attempts. Disengagements during the
i
night for patients newly admitted to the home program
cannot be necessarily regarded as suicidal gestures since
I they must learn how not to compromise the shunt when
| sleeping.
CHAPTER IV
LITERATURE REVIEW OF HOME HEMODIALYSIS:
PSYCHOLOGICAL ASPECTS
j
;Introduction
Perhaps of any chronic illness hemodialysis exacts
the greatest physical and psychological hardships on both
the patient and his family. He must drastically alter his
way of life. He will become less active, more dependent onj
others, and totally dependent on a machine (Coogan, 1969).
The machine will rescue him from death a few times a week.
He will still feel ill a good part of the time and develop
other serious medical complications which may hasten his
death. The symptoms and repeated dialyses are a constant
reminder of his proximity to death; he may develop despair
| (Brand & Komorita, 1966).
j The cost of dialysis is high. Social and economic
I problems add to the strain on the patient and his family
(Curtis et al., 1969). Early in the treatment, when phys
ical and mental effort is impossible, he must make far-
reaching economic decisions such as a change of occupation
or residency or the need for the wife to work (Cramond,
;Knight, Lawrence, Higgins, Court, MacNamara, Clarkson &
i
! 64
Miller, 1968). j
As the patient struggles with accepting and adjust-j
;ing to a life of uncertainty and deprivation, so does the
i
;family. Relationships become strained and family roles
|shift. The stresses of dialysis tend to disrupt the family
i
:(Coogan, 1969). Patients and spouses respond to the
deprivations with feelings of anxiety, depression, frustra
tion, and anger. Disillusionment can set in. For some
I
patients, particularly those with low self-esteem and
lacking firm identifications with their family, friends, or
job, the prolongation of life may not be an important
i
enough goal to justify the real stresses and sacrifices I
necessary to achieve it (Sand et al., 1966). |
This chapter will examine the psychological aspects !
of dialysis including: the psychological stresses to the
patient and family, how they respond emotionally to
dialysis, and the psychological processes involved in
!adaptation to this stressful life on borrowed time.
j
i
Psychological Stresses
Perhaps no situation is as stressful to patients
and their families as chronic dialysis because of the major
readjustment in thinking and living and the constantly
developing crises (Hampers & Schupak, 1967). A person on
chronic hemodialysis experiences a variety of disruptive
stresses. Wright, Sand and Livingston (1966) outlined the
! ' ~ ~ 66
following psychological stresses that may be experienced byj
patients:
j Loss of body function. The patient experiences
I transient states of ill health related to hemodialysis
j
[treatment and chronic medical complications. He may have
iinsomnia. He may have sexual difficulties. He may weigh
much less. Cannula restrictions may prevent writing with
the cannulated arm. Change of body image accompanies loss
of body function. j
Loss of group memberships. The patient may
withdraw from social, athletic, and business clubs or I
|
organizations due to loss of energy or apathy. Avoidance j
by friends and associates is also reported (Short & Wilson, j
1969). The patient may then experience identity losses.
Failure of plans. Home-buying plans may now be
economically unfeasible. Extended vacation plans must be
canceled.
i
Changes in life style. The patient must learn to
restrict physical activity for cannula protection.
Pleasurable active sports such as bowling or tennis must be
given up. Due to unpredictable health he must tolerate
ambiguity and develop flexibility in planning activities.
The need to be dependent on the family and an innate
machine is a source of much stress since the culture
67
stresses independence and acceptance of responsibility
(Hendler et al., 1967). Dialysis often interferes with the
self-sufficiency and the self-confidence of the patient
(Sokol et al., 1967). As the illness progresses the spouse
;slowly takes over the family roles of decision maker and
jbread winner (Hendler et al., 1967). Bedroom plumbing
required in home dialysis may force a housing change.
Loss of job or occunation. The patient may have to
change jobs to accommodate treatment requirements. He may
lose his business built over years. Manual labor is
prohibited. Ill health may restrict the patient to part-
time employment. He may be too ill to work at all.
Loss of home, possessions, or financial status.
This is a strong stress for most patients. With their
income in jeopardy some patients have had visions of
poverty (Hendler et al., 1967). Few patients have total
medical coverage for the high costs of dialysis. Some
Ipatients and spouses see the costs of dialysis requiring a
change in their standard of living as a reason for discon
tinuing treatment (Wright et al., 1966). Sanders and
Dukemiener (1968) state, "For a person with renal failure,
the choice between pauperization and life is a hideous
jone."
68
Iniurv or threat of injury. Patients initially
experience a high level of anxiety regarding the status of
;the cannula site. Each dialysis is a stressful event
i
j(Brown et al., 1962). Generally the patient is trained to
'operate the machine himself and maintain a self-sufficient
i
role while a relative or spouse is trained for emergency
assistance. The patient must properly mix the dialysate
solution, increase or decrease the body blood supply, etc.
The machine can malfunction. Patients fear human error or
equipment unreliability. Their fears, to some extent, are
real fears.
Frustration in drives. Patients used to eating
large quantities of food, especially meat, are particularly
frustrated by dietary restrictions. Fluid restrictions are
stressful (Brown et al., 1962). Impotency or a decline in
sexual drive develops. This may result from feeling ill,
depression, or changes in body image. The spouses may
|experience decreased sexual desire for the patient.
| Secondary drives such as the need for power or acquisition
j
|are thwarted.
|
Hemodialysis patients must then be able to tolerate
frequent stressful situations including uncertainty about
life expectancy, forced changes in life style, and reoccur-
i
jring medical complications and emergencies (Sand et al.,
1 1966). In the first six months of radical adjustment, the
; " ................ ””” ’ .. 69
stresses are experienced in the minor but important aspects
of life such as: less active social and family participa
tion, the need to restrict hobbies and interests, and the
monotony of the diet (Curtis et al., 1969; Leopold, 1968).
j In normal living daily stresses are coped with by
adaptive or defensive devices such as eating, smoking, use
of alcohol, physical exercise, or sex. Patients with
chronic renal failure and loss of libido are deprived of
|
many of these tension outlets (Cramond et al., 1968).
Patients may cope with the tension and stresses of dialysis I
and daily living by other outlets which are cruder, more j
disturbing, and less economical. Reactions like insomnia,
nightmares, suicidal depression, and even epileptic seiz- j
ures are such tension outlets. Self-administered relaxa
tion therapy has been proposed as a more effective and less
harmful means of reducing tension (Cramond et al., 1968).
Psychological Process During Dialysis
Curtis et al. (1969) and Abram (1968; 1969b) have
described the psychological phases that the patient goes
through during the first year of dialysis. A synthesis of
their descriptions follows.
Phase I--uremic syndrome. The patient with terminal
renal failure may have the following uremic symptoms:
i
|fatigue, apathy, drowsiness, poor concentration, depression,
!
[and irritability. Denial emerges as a primary defense and_
; ............ .......... .."""............. ” 70
serves as protection from unwanted facts. The implications
of the illness and treatment are gradual. However, acutely!
ill patients have more difficulty accepting the reality of
a fatal illness and that they will die without treatment.
With the mild mental confusion experienced, there is
a . weakening of ego function especially in the areas of
impulse control, reality testing, and defensive functions j
|
(Daly, 1969). Patients become more irritated as they are j
less able to sublimate aggression. Increased use of denial
and projection results in very defensive, often paranoid,
behavior. Temper outbursts are followed by guilt (Daly, i
1969). i
!
As they begin to accept the reality of this |
predicament, the prominent affect is depression and the
main thought content is awareness of death (Abram, 1968).
I Phase II--shift to physiological equilibrium (first
to third week). The apathy experienced during the first to
|third dialysis lessens as the patient approaches physiolog-
jical equilibrium. As he begins to feel better, the patient
I
has a brief period of euphoria at his return from death and
is glad to be alive. He becomes more aware of the dialysis
process. He experiences acute anxiety during the first few
dialysis runs.
Phase III--convalescence and return to living
(third week to third month). Physiological equilibrium is
: 711
reached by the fourth week. The patient must face the j
realities of the situation. He is physically weak, still
:anxious, and may vomit or have headaches. But he returns
I to living and looks ahead. Depression occurs as the prob-
i
Ilems of life become apparent. Anger and resentment about
the illness can result in occasional resentment to the
medical staff.
I
i
The dependency-independency conflict emerges. The |
patient can give in to dependency by: excessive demands,
development of multiple somatic concerns, or refusing to
leave the unit and return to work. Or the patient may
yield to independency and express bravado-like rebellion to ,
the program. As the time arises to leave the hospital and j
give up his regressed position, the dependency-independency:
conflict increases. He must be gradually pushed into the j
world and his "healthy" independency allowed to dominate.
I This phase begins in the first month and may last eighteen
Imonths.
j
! Phase IV— struggle for normalcy (third to twelfth
months). The patient struggles with the problem of living
i
Jrather than dying. He gradually accepts his lost health
|
jand the basic readjustment to life style required. He
!adjusts to the routine. He becomes more relaxed and
I
; reassured as treatment continues successfully. He sleeps
through dialysis. However, medical complications result in
72
depression and reawakened anxiety. The greatest agitation
and depression occur when another patient becomes acutely
[ill, is prepared for transplant, or dies (Shea, Bogdan, I
I
Freeman & Schreiner, 1965; Tsaltas, 1967). The death of
i
ianother patient has a damaging effect on morale (Curtis
[
;et al., 1969).
The patient gropes with the issue of life worth
living. Hope overbalances despair (Abrams, 1969b). Some I
patients develop an "anniversary reaction" with an increase i
in anxiety around the end of the first year.
In summary, the psychological process involves
initial acute anxiety or denial, followed by depression,
increasing dependency, and finally in most cases a gradual I
acceptance of a new life style.
Body Image
Changes in self-image occur during chronic dialysis
iwhich the patient must defend against (Wright et al.,
11966). A person's self-image may be based on such things
las: job efficiency, economic status, future aspirations,
physical appearance, and attractiveness (Wright et al.,
1966). The accommodation to a loss of self-image is a
problem especially felt by previously independent males
| (Schreiner, 1969). Young women are particularly sensitive
|to the effect the shunt has on their appearance. Coogan
| (1969) described a young girl who was sensitive to the
73 |
disfigurement of the shunt near her wrist. |
The changes in life style required by dialysis
:demands are stressful to the degree they affect the
I
I patient's self-image (Wright et al., 1966). Defenses
against changes in self-image include the use of denial or
|projection (Wright et al., 1966). In one study involving
psychological tests, some patients had an inflated self-
image score (De-Nour, Shaltiel & Czaczkes, 1968). This mayj
reflect their struggle against dependency by unrealisti-
i
I
cally trying to master uncontrollable situations (De-Nour I
i
et al., 1968). |
Another problem of dialysis patients is the j
disturbance in body image that occurs in patients with ;
i
artificial organs (Abrams, 1969b). One adolescent who ■
|
viewed dialysis as a threat to his identity had hysterical
outbursts during dialysis. Figure drawings prior to his
death, which consisted of a head and cylindrical torso
I similar in appearance to a dialyzer, showed his ultimate
iloss in personal identity (Shea et al., 1965).
I
Another patient saw himself as a broken, disjointed
man controlled by strings in his arms, a sick puppet
(Kemph, 1966). At the time, he had blood pressure apparatus
in one arm and tubing connected to the machine in the other.
Since dialysis is an unusual experience it could be
expected to figure in unconscious fantasy (Kemph, 1966).
[A frequent underlying fantasy theme is related to science
74
fiction involving the robotization of human beings (Abram,
:1969b). Some patients feel that they are not fully human !
since a vital organ is artificial; therefore, they see
themselves as zombies or androids (Abram, 1969a). Patients
land spouses also experience an umbilical fantasy based on
I the attachment through his bloodstream and tubing to some
thing that maintains life (Shambaugh, Hampers, Baily,
Snyder & Merrill, 1967; Wright et al., 1966). j
Abram (1969b) concluded that the patient incor- j
i
porates the machine, on which he is dependent for life,
into his body image. He then unconsciously thinks of
himself as not entirely human and therefore freakish. The j
fantasies are unconscious and reveal the patient's symbi-
i
otic and conflictual relationship with the machine. '
Dialysis patients see themselves as nonhuman because in
reality a part of their body is innate (Abram, 1969b).
Emotional Reactions
I Dialysis patients may have difficulty in maintain-
I
| ing their emotional equilibrium due to the nature of
chronic renal failure, the restrictions imposed, and the
repetition of treatment (Brand & Komorita, 1966). The
slightest mishap can upset their emotional balance (Shea
et al., 1965). Chronic illnesses such as dialysis make
demands that may be temporarily intolerable for even the
most stable personality (MacNamara, 1967).
75 i
A whole range of emotional responses can arise from
■simple anxiety to severe depression and suicidal attempts
(Sokol et al., 1967). All dialysis patients have varying
jdegrees of mood swing. Depression, anxiety, frustration,
j
|and anger are the main symptoms of stress. Their appear-
jance is often associated with crises of a physical or social
nature (Curtis et al., 1969).
i
Depression. The onset of depression after begin- j
[
ning dialysis is based on: the awareness of impending j
death, the narrowing of activities arising from the role of t
i
a patient, and the awareness of impaired ego function
(Kemph, 1969). Along with depression patients experienced:
(a) intense guilt related to the illness and how they might I
atone and magically get rid of it; (b) a strong regressive I
temptation to give up; (c) anger at themselves, others, and
fate for letting this happen; and (d) a masochistic use of
the situation (Kemph, 1969).
j Later in treatment transient depression may
jperiodically occur which usually lasts one to two days
I
I (De-Nour et al., 1968). Depression occurs when denial or
other defenses fail (Wright et al., 1966). The patient may
be unaware that he is depressed (Wright et al., 1966). An
independent, denying patient is susceptible to depression
when fatigue and other symptoms impose restrictions that
the physician could not get him to accept (Norris, 1968).
76
A study using repeated MMPI tests on dialysis
patients disclosed more depression than the normal popula
tion (Wright et al., 1966). Responses closely resembled
|
jthose of groups of other patients with chronic illness,
j A more lasting and very predictable problem is the
j
periodic depression comparable to mourning. The self-
i
mourning process generally requires at least six months.
Depression results in apathy or unconscious neglect of the
treatment regime (Wright et al., 1966). I
Patients show different degrees of depression. |
Some act morose and quite lethargic while others, who have |
a better prognosis, seem defeated at times but can brighten |
up with mild encouragement (Enelow & Freed, 1967).
Extreme depression may result in suicidal impulses.
Patients consciously or unconsciously try to hasten their
death by using the machine inappropriately or insuffi
ciently or by refusing to follow their diet (Coogan, 1969).
|One depressed patient voluntarily discontinued his diet and
jdied four days later (Shaw et al., 1965).
Anger. Patients express anger to frustration,
especially when they are unable to sublimate their hostil
ity. Patients have trouble in dealing with their hostility
to: the illness, treatment, relatives, God, or fate (Daly,
1969). Despite a good understanding of their diet, they
jbecome angry when refused a forbidden food (Daly, 1969).
77 I
The hostility in the initial weeks to the fluid restriction;
disappears after the patient becomes aware of the benefits
derived (LoCicero, Kahana & Price, 1967).
| A study of dialysis patients disclosed that older
I
|patients were happier, more law-abiding, and less hostile
(Daly, 1969). The study used psychological tests including
the Hostility Scale. Duration of patient treatment varied
I i
from several months to five years. The hostility in ;
dialysis patients was not more significant than the general!
population. However, younger patients had a greater burden;
in terms of role adjustment and hostility. j
Daly (1969) further found a wide range in the \
amount of patients' hostility and ability to deal with it !
in an adaptive way. Patients expressed hostility by com
plaining about the dietary restrictions or by repeated
requests for special attention. Hostility to the nurses
was indirectly expressed by sarcastic jokes. Hostility to
I the physicians was displaced to the machine or to the
[technicians (Daly, 1969).
Patients have a problem expressing even justifiable
anger with the staff on which they are dependent because
they fear that they will be taken off the machine (Abram,
1969a; MacNamara, 1967). Therefore the patient needs to be
|helped to express hostility. The staff needs to accept his
I
I anger without feeling frustration or rejection towards the
j
jpatient (Abram, 1969a).
78
Anxiety. The psychological stresses, including
financial worries and changes in life style, previously
jmentioned are a strain on the patient and his family and
jresult in anxiety (Brand & Komorita, 1966; Curtis et al.,
|1969; Leopold, 1968). It has been stated that the hemo-
;dialysis patient lives in a state of suppressed inner
turmoil from which there is no escape except death (Journal
of the American Medical Association, 1966).
A great portion of experienced anxiety is related
to the treatment. Patients initially have anxiety about
the functioning of the shunt and its relationship to their
longevity. The initial episode of clotting causes great
concern and depression since it is a threat to their
existence (Hampers & Schupak, 1967, p. 148). Blood trans
fusions create anxiety (Brand & Komorita, 1966). The
patient is constantly reminded of his dependence on the
machine and staff and is constantly exposed to the hazards
I of treatment. This results in anxiety about the treatment
|such as fear of mechanical failure during sleep or of
i
jbleeding to death (Brand & Komorita, 1966).
The highly independent patient handles anxiety
through action. His struggle against the illness often
I
causes him to ignore dietary or physical restrictions
i(Norris, 1968).
j
The patient experiences anxiety during periods of
: ."" ' 79
cannula or medical problems; he generally leads a well-
iadjusted life when things go smoothly (Eschbach et al., j
11967). The number of problems and degree of anxiety
Idecrease with time as the patient gains confidence in his
j
jability to handle malfunctions (Eschbach et al., 1967).
i
iHowever, patients have expressed intense fear of dialysis
and intractable insomnia after seven months of treatment
(Brown et al., 1962).
Defense Mechanisms
To tolerate the stresses and anxiety involved with !
j
dialysis, the patient must have adaptive defense mechanisms :
for successful adjustment. De-Nour et al. (1968) found
uniform defenses of: denial, displacement, isolation of j
i
affect, projection, and reaction formation to aggression in
all patients.
Denial. Denial is the major defense mechanism of
|dialysis patients. The patient denies: (a) the original
|disease, (b) dependence on the machine and staff, (c) the
|danger of death, and (d) emotional or sexual problems
(De-Nour et al., 1968).
Denial of the prognosis is greater in patients with
acute failure who are too ill to participate in the treat
ment decision (Brand & Komorita, 1966). Patients initially
deny the irreversibility of their condition and may feel
that the shunt is temporary until their kidneys start_______
working again (Brand & Komorita, 1966). A few patients in :
denying the illness, or as a suicidal gesture, frequently j
isubject the cannula to unnecessary trauma (Shea et al.,
j1965).
T he i n i t i a l d e n i a l o f t h e p a t i e n t m ay p r e v e n t h im
: fr o m h e a r i n g i n s t r u c t i o n s o r i n f o r m a t i o n w h ic h m u s t b e
r e p e a t e d l y g i v e n w i t h o u t l o s s o f p a t i e n c e o r r e j e c t i o n o f
t h e p a t i e n t a s s t u p i d o r u n c o o p e r a t i v e (B r a n d & K o m o r ita ,
1966; C ram ond e t a l . , 1968). P a t i e n t s w i t h o u t i n i t i a l j
I
d e n i a l h a v e m o r e a n x i e t y a n d d e p r e s s i o n e a r l y i n t r e a t m e n t !
j
b e f o r e c o p i n g w i t h t h e i r f e e l i n g s a n d a d a p t i n g ( N o r r i s , j
•1968).
D e n i a l i s common a n d s e r v e s a s a u s e f u l , e f f e c t i v e
m e n t a l m e c h a n is m t o h e l p t h e p a t i e n t c o p e w i t h a c o n t i n u i n g
u n s a t i s f a c t o r y c o n d i t i o n (C o o g a n , 1969; M acN am ara, 1967;
S h o r t & W i l s o n , 1969; W r ig h t e t a l . , 1966). D e n i a l a l s o
h e l p s t h e p a t i e n t t o c o p e w i t h t h e o c c u r r i n g o r g a n i c b r a i n
! d y s f u n c t i o n a n d w i t h s i m u l t a n e o u s m e d i c a l c o m p l i c a t i o n s
j ( S h o r t & W i l s o n , 1969). T h e s t r o n g u s e o f d e f e n s e s w h ic h
w o u ld b e m a l a d a p t i v e i n n o r m a l p e o p l e i s a d a p t i v e f o r
d i a l y s i s p a t i e n t s .
I n i t i a l d e n i a l c e a s e s a s t h e p a t i e n t a c h i e v e s
i n s i g h t o f a n u n c e r t a i n f u t u r e , a c c e p t s t h e r e g im e
l i m i t a t i o n s , a n d a t t e m p t s t o c a r r y o n a s u s u a l ( S h o r t &
jWilson, 1969). But he soon becomes aware that his self-
!
|e x p e c t a t i o n s e x c e e d h i s p h y s i c a l c a p a c i t i e s . He t h e n
81 j
minimizes the significance of the limitation to begin the
continued reinforcement process of denial (Short & Wilson,
1969).
Over time, dialysis patients show an MMPI profile
of low anxiety and high repression, the unconscious deriva
tive of denial (Short & Wilson, 1969). During acute stress
and medical crises, the pattern becomes more pronounced
indicating an ability to mobilize even more denial (Short &
Wilson, 1969). Since patients had previously accepted
their condition, during a time of crisis they deny that it i
is happening now and continue to expect a reversal or feel |
that the problem will not reoccur (Short & Wilson, 1969).
The prevalence of denial has also been confirmed in !
j
a self-rating scale where the majority of patients rated j
themselves as definitely happier than other dialysis
patients (Wright et al., 1966). Denial is an inevitable
^consequence of chronic dialysis (Short & Wilson, 1969).
Displacement. The intense preoccupation with the
!
!shunt is a displacement of the fear of bodily changes or of
i
|threat of major mutilation and death to something less
terrifying and controllable. Focus on the shunt also has
the means of mastery via meticulous care (De-Nour et al.,
1968).
Isolation of affect. Patients appear carefree and
show no emotion when discussing distressing topics (De-Nour
et al., 1968).
Projection. The patient's great bewilderment and
i fear of bodily changes plus the demands for coping behavior
j a r e p r o j e c t e d t o f a m i l y a n d f r i e n d s . T he p r o j e c t i o n s
!
[rarely reveal the underlying aggression to the staff.
i
I Projection generally does not reach the degree of distort
ing reality (De-Nour et al., 1968).
Reaction formation to aggression. Patients
uniformly: do not act out, have an absence of overt
aggression, and are extremely cooperative with the staff
(De-Nour et al., 1968).
Intellectualization. Patients have defended
through intellectualization by never experiencing a con
scious need for dialysis but rather logically realizing the
need to live. Decisions were made on a rational basis with
jlittle regard for feelings (Kemph, 1966). One example is a
chemist who used intellectualization as a major defense and
j
I could talk about dialysis which is a topic most patients
t
a v o i d (S h e a e t a l . , 1965).
Repression. A patient in treatment over seven
months stated that she just did not think about it (Brand &
Komorita, 1966). To continue to live on dialysis with
simultaneous major medical complications would require
repression (Short 6c Wilson, 1969).
83
De-Nour et al. (1968) found that while these
uniform defenses were adaptive, they led to marked ego
irestriction. Marked ego restriction was manifest by:
! (a) shallow object relations with superficial emotional
I
jinvolvement, (b) limited interest in people or events
joutside the hospital, (c) hobbies nonexistent, (d) limited
iadaptability to new life situations, (e) demanding situa
tions ignored, and (f) development of transient psychiatric
symptoms if the demanding situation was sufficiently
stressful to break down the defenses. The defenses were
rigid, inflexible, brittle, and vulnerable to transient
breakdown with resulting anxiety and depression.
De-Nour et al. (1968) hypothesized that the main
problem, stress, and threat of dialysis patients is not the
threat of death but of the dependency on the machines and
staff and the aggression resulting from this dependency.
|The dependency on hemodialysis is unique and similar to an
infant's dependency on his mother. Even if the patient
j
|could consciously or unconsciously accept his dependency
Ineeds, this complete dependency results in aggression. The
expression of aggression is too dangerous so defenses are
mobilized against dependency and aggression. The defenses
then ward off anxiety but impoverish the personality.
84 |
Dependency !
; _ i
Dialysis patients are subjected to an extreme j
i
; dependency-independency conflict of being totally dependent
on the machine and renal unit personnel, yet needing to be
sufficiently independent to lead a normal existence outside
i
jof the unit (Abram, 1969a).
This conflict can be manifest in a variety of
behaviors ranging from extreme anxiety when away from the
apparatus to phobia at the discomfort and confinement
during dialysis (Kemph, 1966). Insecurity and dependency
may be manifest as assertiveness including such behaviors j
i
as: (a) hostility to the staff, (b) resentment to other i
i
patients or family members, (c) abuse of medications or
lack of following the diet, or (d) suicide (Schreiner, j
1969). Dependency on the machine can be a complicated,
stressful relationship in emotionally unstable or immature
patients (Sokol et al., 1967).
One patient who was extremely threatened by his
;dependent position was negative and uncooperative as he
Istruggled with this conflict. His expression of independ
ence in a counterphobic or reaction formation manner helped
his return to normalcy (Abram, 1968).
Patients who are too dependent do not want to go
home and become panicked at home dialysis training or are
slow to learn (Coogan, 1969).
Excessive dependency on spouses can be avoided by
85
teaching the patient to be self-responsible for his care.
! j
Two patients, dialyzed by their wives, had much hostility j
|to their spouses and denial which made it difficult for the
wives to cope with these added stresses and burdens
(Eschbach et al., 1967).
j
I Patients may become extremely dependent on physi-
|cians which results in great emotional stress if the
physician departs (Hampers & Schupak, 1967). Patients have
i
shown deteriorated behavior when a favorite or trusted j
staff member is temporarily away (Cramond et al., 1968). j
i
The resulting crisis situation involves anxiety or extra j
work for the staff member upon his return; the patient has
gained extra attention and punished the staff member for
abandoning him (Cramond et al., 1968).
A case was reported of a patient with severe
depression during the initial months of dialysis who
responded to a dependent relationship with the physician.
[When the doctor moved, the patient became depressed and
|apathetic and would not eat or talk. He no longer trusted
|
'anyone and wanted to die. His despair and giving up
resulted in malnutrition and depression which precipitated
death (Kemph, 1966).
r ’ 861
Psychiatric Disorders
Studies have reported severe emotional disorders j
|associated with chronic hemodialysis including: (a) severe
!
depression (Gombos et al., 1964; Gonzalez et al., 1963;
Kemph, 1966; Retan & Lewis, 1965; Shaw et al., 1965; Shea
et al., 1965), (b) apparent psychosis (Maher et al., 1965),
(c) paranoid psychosis (Brown et al., 1962; Gonzalez et al.3
1963; Kemph, 1966), (d) hypomanic psychosis (Cooper, 1967), j
(e) delusion of spontaneous recovery resulting in death
(Abram, 1968), (f) psychotic denial of illness (Abram,
1968, 1969b), (g) hallucinations (Enelow & Freed, 1967; j
Kemph, 1966), or (h) requests by the patient to terminate !
treatment (Schreiner & Maher, 1965).
The current gross psychosis in patients has been
reduced sharply from the earlier incidence by prompt
supportive intervention (Coogan, 1969). Treatment centers
Jhave reported no need for psychiatric treatment in patients
1 (Curtis et al., 1969; Johnson et al., 1970).
i
I Sometimes the psychotic behavior is related to a
i
metabolic disturbance since there is recovery with hemo
dialysis (Brown et al., 1962). It is also not clear to
what extent psychotic behavior is due to the organic
changes that occur or whether the personality deterioration
is due to continual stress (Enelow & Freed, 1967).
In the case of a hypomanic psychosis precipitated
by dialysis of a 35-year-old female patient who had been on
87 !
dialysis 13 months, the psychotic behavior was manifested
by euphoria and delusions that her mother was alive and that
I the patient was pregnant. Her dependency conflict with the
j
Imachine was illustrated by her hatred of the machine and
I
J
ithe endowment of human motives to it such as patronizing
I
iher. The psychosis, which occurred when her shunt clotted
land when she was at a low emotional ebb, lasted about two
weeks. There was no remission. The author concluded that
the psychosis was not of uremic origin but functional and j
due to accumulated psychological stresses including:
religious conflicts, refusal to accept her mother's death, j
and sterility. The psychosis was triggered by repeated j
dialysis (Cooper, 1967). !
Hallucinations generally are related to emotional j
needs (Kemph, 1966). Kemph reported of a 15-year-old girl
who had delusions of seeing her father which related to her
!increased affection for the father and the need to have him
with her since she became seriously ill. Another patient
jwith considerable depression was absorbed in bodily
preoccupations, had an intense clinging to his wife, and
hallucinated frequently during center dialysis (Enelow &
Freed, 1967).
The small number of patients asking to be withdrawn
from the program and the larger number of patients who can
not adhere to the diet and other restrictions illustrates
the chronic stress of dialysis (Abram, 1968). The number
r ~ " 88
I
of suicidal binges and cannula failures related to emotional
factors may be more common than believed (Abram, 1968). |
Psychotic symptoms are more likely to appear when
i
|the patient had to function independently and make decisions
|
|on trivial matters (De-Nour et al., 1968). Psychiatric
isymptoms disappear during hospitalization since the patient
can regress. When "sick," dependency is acceptable and
aggression and defenses are lowered (De-Nour et al., 1968). j
The development of self-reliance by the patient may minimize
psychotic symptoms (Sokol et al., 1967). The emotional
problems in home dialysis patients are greater than those j
in patients treated in a hospital, but the emotional prob- j
lems of all patients improve during the first year
(de Wardener, 1968).
Effect on Spouse and Family
It is generally agreed that patients with strong
jfamily support have a better prognosis. Although assertive,
jenergetic patients have less need for support, mothering
]
land nurturant wives are an important psychotherapeutic aid
to dialysis (Enelow & Freed, 1967). Wives are influential
in determining the patient's: attitude towards chronic
illness, cooperation with the dialysis regime, and level of
morale (Meldrum, Wolfram & Rubini, 1968). However, an
i
jeffort to study the family at the time of acceptance into
home training has not been successful in terms of predicting
? '...... . . .."" 89
future dialysis management behavior (Pentecost, 1970). i
All members of the patient's immediate family are j
, affected emotionally and materially by dialysis (MacNamara,
!1967). Reports have shown that the stress of home dialysis
j is felt more by the spouse than by patients (Hampers,
| Merrill & Cameron, 1965; Shambaugh et al., 1967). The
deprivations and hardships of dialysis may lead to frustra
tions and tensions in family members which makes support to
the patient difficult. Furthermore, dialysis can result in
i
family pathology. Divorce is frequent (Coogan, 1969). !
Occasionally the stresses of dialysis brings the
family closer together (Curtis et al., 1969). This is !
especially true where an unneeded spouse or inconspicuous j
family member becomes important or where siblings band
together (Hampers & Schupak, 1967).
This section will examine some of the effects of
dialysis on the family.
Emotional impact on the spouse. Shambaugh et al.
|(1967) comprehensively examined the emotional impact of
j dialysis on the spouse. Psychological stresses on the
spouse include: (a) the patient's possible death, (b)
medical expenses, (c) loss of income, recreation, and
travel, (d) shift in husband's dominant role, (e) refusal
|of relatives to donate a kidney, (f) emotional disturbances
in the children, and (g) the decline in the patient's
sexual ability (Shambaugh et al., 1967).
Impotency can result in understandable arguments and
estrangement (Leopold, 1968). Spouses are also distressed
by the separations necessary for treatment and the patient's
dependent demands (Wright et al., 1966). Patients commonly
regress and are infantile, demanding, self-centered, crit-
jical, and unaccepting of their illness which makes them
quite different than the people the spouses had married
(Shambaugh et al., 1967; Shambaugh & Kanter, 1969). [
j
Stresses are more severely felt during acute family
or medical crises. Spouses experience severe losses and
frustrations from psychological stresses (Shambaugh et al., j
1967) . They react with intense emotional feelings of j
deprivation, anxiety, depression, and hostility uncon- j
sciously directed to the patients. Spouses may respond to j
emotional distress by maladaptive, severe reactions of:
(a) disorganization, (b) somatization, (c) depression, (d)
displacement of anger, guilt, and depression, (e) denial
|and avoidance, (f) excessive symbiotic closeness, or (g)
[premature mourning (Shambaugh et al., 1967). Fatigue is
!
Icommon (Curtis et al., 1969). Families prematurely may
withdraw their emotional investment in the patient.
Various studies have reported on spouse pathology
including: (a) heavy drinking (Hampers & Schupak, 1967),
|(b) excessive anxiety (Curtis et al., 1969; Hampers &
jSchupak, 1967), (c) depressive reactions (Curtis et al.,
1969; Hampers & Merrill, 1966; Hampers & Schupak, 1967;
Tenckhoff, Shilipetar & Boen, 1965), (d) insomnia during
night dialysis (Curtis et al., 1969), and (e) schizophrenia:
(Shambaugh et al., 1967).
i
!
Responsibility for home dialysis. Various studies
j
|confirmed that spouse and family tensions and hostility are
decreased where the patient assumes primary responsibility
for home dialysis (Coogan, 1969; Dawborn, Fahl & Marshall, I
1968; Hampers & Schupak, 1967; MacNamara, 1967). Spouses j
i
who operate the machine are under severe stress in handling
their unconscious hostility to the patient (Shambaugh
et al., 1967). They resent the burden and are afraid of
i
their homicidal thoughts to the incapacitated patient
(Hampers & Schupak, 1967; Shambaugh et al., 1967). Spousesj
who operate the machine need to be helped to face their j
homicidal thoughts without undue guilt or fear (Coogan,
1969).
! When home dialysis was first initiated, spouses
Iwere trained to operate the machine. However, most centers
I
jnow avoid the increased stress and conflict for both the
patient and his spouse by making the patient self-respon
sible for dialysis.
i Family problems through role shift. Family role
relationships are markedly altered by dialysis. Wives are
frequently burdened with earning a living as well as caring
for the home, patient, and children (Leopold, 1968) . Also,
92
as the patient's illness necessitates a role shift, the
wife must assume and accept instrumental and authority
!roles (Enelow & Freed, 1967). Meldrum et al. (1968) felt
!that younger wives can adjust better since they have more
I marketable skills and the flexibility of youth.
Spouses frequently feel ambivalence to the patient
because they resent the extra responsibility and family
burden (Hampers & Schupak, 1967). Spouses complain of the
enormous extra work of home dialysis when they have little j
to do with the operation (Curtis et al., 1969). j
Along with assuming the extra responsibilities, j
j
spouses have to give sympathy to the husband, who may often I
I
be irritable and depressed, when the demands on her are |
i
overwhelming (Leopold, 1968). As previously stated, the j
dialysis patient becomes short-tempered and difficult to
live with (Curtis et al., 1969; Shambaugh et al., 1967).
Dialysis patients who are parents often lose patience with
their children which becomes an additional source of family
itension. Some spouses have stated that only guilt kept
them from abandoning the patient (Shambaugh et al., 1967).
Families occasionally expect a higher level of
well-being in the patient than is realistic (Wright et al.,
1966). Since the patient does not necessarily appear
I physically ill, families or employers may be less tolerant
!
of the patient's inactivity (Brand & Komorita, 1966).
Families need help in avoiding unrealistic expectations or
93 |
overprotectiveness (Brand & Komorita, 1966). j
Little has been written on the effects of dialysis ;
on the children in the family. It is too soon to assess any
i
ilong-term traumatic effects which the illness of a parent
has on children (Curtis et al., 1969). Anxiety and aggres
sion has resulted in: physical violence of kicking at the
parent's shunt, incontinence, and slow learning (Curtis
!
et al., 1969). The child's successful adjustment is related;
to the parents' acceptance of the situation, and with women !
patients the quality of mothering they are able to give the i
child (Curtis et al., 1969). It may take up to a year for !
i
female patients to fully resume their mothering role j
(MacNamara, 1967). I
!
Family denial. Short and Wilson (1969) traced the
shift in family process and maladaptive denial that can
occur. They stated that the family initially accommodates
with good faith and motivation, but continued dialysis can
leventuate in the decay of the patient and home situation.
;As the family shares the stresses and disappointments of
the patient, the uncertainty wears on the spouse. Initial
hope turns to weary accommodation of living on borrowed
time. The patient becomes more of a spectator in the home
and a dependent member. The altered marital roles makes
the partners more distant, especially if the patient is male
(Short & Wilson, 1969). There is a distortion of the father
r — ....... .‘ ' ““ ~ ~~ 94
ifunction to come home and be hooked up to a machine instead j
| ;
of playing with the children (Fellows, 1966).
For self-protection, the spouse begins to question
the decision of dialysis (Short & Wilson, 1969). Hostile
feelings are rationalized that the patient would be better
out of his misery. Hostile feelings can be displaced to the;
medical team.
Family denial then occurs (Short & Wilson, 1969).
The changes in the patient, his exclusion from decisions,
i :
jand the emotional withdrawal of the children and spouse from
j !
|the patient are denied. Changes are ignored and situations
i i
jproducing them avoided. This form of denial is maladjustive!
^for the family. They need help to later handle normal grief
without excessive guilt (Short & Wilson, 1969).
; |
Psychological Adjustment
Some patients take six to twelve months to become
! ;
well adjusted (Eschbach et al., 1967). Patients must face i
;the reality of their illness. Psychological acceptance is
necessary for success (Barber et al., 1963; Shea et al.,
11965). The burden of adjustment occurs to a future of ;
i i
uncertainty and reoccurring physiological upsets and imbal- j
j ■ ;
ances; however, most patients become philosophical about
! I
these annoyances (Norton, 1967). The patient who does the ]
best psychologically has the self-confidence that life is
worth living even if restricted (Leopold, 1968). Curtis j
et al. (1969) noted that successful patients were remark-
:edly cheerful and evolved their own individual philosophy j
!for living such as "half a loaf is better than none" or
"I live from day to day enjoying each as it comes."
i
| Self-discipline and continuing to work and to lead
I a full life are also important for good adjustment (Curtis
et al., 1969; Leopold, 1968).
Various authors mentioned a supportive, unified
I
family as a crucial factor of successful adjustment (Curtis j
et al., 1969; Hendler et al., 1967; Leopold et al., 1968). j
i
The patient who does the best psychologically has suppor- i
tive friends and family who are not overprotective
(Leopold, 1968). Where patients lack integrated social
support there is poor adjustment manifested in marital
stress, job instability, role conflict, and dependency
problems (Hendler et al., 1967).
There are variations in adaptation to chronic hemo-
|dialysis. Some patients identify with the personnel and
jmake suggestions or perform simple chores. Some deny the
threatening situation and assume superficial optimism or
engage in inappropriate future planning. Others appear
totally disinterested during dialysis while actually being
most frightened and apprehensive and clinging to every word
said (Hampers & Schupak, 1967).
Acute patients have a greater problem with adapta-
i
jtion. They manifest more: depression, self pity, lack of
[desire for constructive planning, and security sought by
reflecting on the past (Hampers & Schupak, 1967).
Three major factors to successful psychological
|rehabilitation are: (a) sufficient dialysis three times a
week eight to ten hours so azotemia will not interfere with
[the patient's ability to adjust to stress, (b) thorough
[training emphasizing self-dialysis, and (c) support by the
physician (Eschbach et al., 1967).
Management and Staff Implications
Some authors have made comments or suggestions i
!
regarding management of patients for good adaptation. The
effect of staff interrelationship with the patient's ;
adjustment has also been mentioned. The staff and medical
atmosphere play an important role in the patient's adjust
ment (Brand & Komorita, 1966; Brengelmann, 1968; Enelow &
;Freed, 1967).
| The staff must recognize that cooperation fluctuates
i
[with the circumstance or mood in the individual patient
(Barber et al., 1963). Because of lifelong personality
disorders, some patients create obstacles in the way of
treatment resulting in failure to keep appointments or to
take proper care of the shunt (Enelow & Freed, 1967).
Self-care problems can be expected with the following types
of patients: (a) self-destructive person, (b) a person
with an authority problem, (c) a defensive hypermasculine
97 !
I i
male who denies his disability and dependency needs, and
(d) a person with a history of impulsive behavior (Sand I
| et al., 1966).
j Excessive dependency in a dependent patient can be
j avoided by an early, vigorous program of activity and
j
| rehabilitation (Norris, 1968). High expectation of social
functioning by the staff and family can prevent the patient
from adopting an invalid role. However, the independent
type of patient finds restrictions difficult; therefore, j
the staff should go easy on him until he comes around. j
Excessive expectations by the staff early in treatment only!
results in alienation and depression in an independent |
j
patient (Norris, 1968). ;
The staff must recognize and accept the patient's
temporary feelings of inadequacy and yet help him to manage
his own affairs as soon as possible to maintain his self-
; confidence (MacNamara, 1967). More self-responsibility
i
results in a changed self-image reflecting more positive
aspects of the personality (MacNamara, 1967).
Patients with paranoid or obsessional traits must
be briefed as fully as possible (MacNamara, 1967).
In order to live with an artificial kidney and the
symptoms of renal failure, the patient may need to adjust
his self-expectations (Brand 6c Komorita, 1966). Therefore,
the patient needs understanding and continued emotional
[support from the family and medical staff. The problems of^
rehabilitation and adjustment to chronic dialysis, espe-
!cially the problems regarding the dependency-independency
|conflict and the meaning of prolongation of life, need
|attention and understanding (Abram, 1968). Unfortunately
I the mature couple who try to cope with practical problems
; and are outwardly controlled may obtain less help than the
patient who draws attention to his needs (Curtis et al.,
1969; MacNamara, 1967). i
|
To achieve the goal of hemodialysis, the preserva- j
I
tion of a sense of well-being, there is a need for ongoing j
psychological and sociological support (Brand & Komorita, !
]
1966). The patient’s tensions are reduced by being able to!
verbalize his problems in the presence of a nonjudgemental j
but receptive listener (Brand & Komorita, 1966). If the I
patient is allowed to express his depression when complica-
;tions arise, the patient is relieved to find his feelings
|of ambivalence and depression acceptable and is helped to
iendure dialysis (Abram, 1969a). It is reassuring to the
!patient to know that in reality dialysis can lead to
despair (Abram, 1969a)
| It may be extremely dangerous to the patient to
break down his defenses (Brand & Komorita, 1966). Denial
|to cope with the situation is a blessing for the patient
|and no attempt should be made to substitute a more realis-
|tic attitude (Coogan, 1969).
99 !
Group therapy sessions for patients have helped
alleviate anxiety, anger, and depression; and the patients
|helped each other to gain more self-respect and morale
(Coogan, 1969). Successful results are also reported in
group therapy for spouses (Shambaugh & Kanter, 1969).
Modern conditioning techniques have been recommended for
alleviating anxiety symptoms in patients (Brenglemann,
1968).
Staff therapy has been recommended to help the
staff develop a comfortable rapport with the patient and to j
I
i
maintain a proper psychic distance so they are not over- j
j
whelmed by the patient's tragedy (Coogan, 1969). Emotional
problems in the medical team of the unit primarily involve
reactions of: guilt, possessiveness, overprotectiveness,
or withdrawal from the patients (De-Nour & Czackes, 1968).
Demands that the patient do well in treatment are based on:
jstaff doubts arising from patient anxiety, staff doubts of
j treatment worth, or guilt over selection of patients
i
(De-Nour & Czackes, 1968).
Denial is inappropriate for physicians and nurses
responsible for the care of the patient (Short & Wilson,
1969) . Nurses must recognize that patient complaints and
demands are requests for attention. Nurses must neither
ignore nor cater to the patient's whims since this results
in guilt and anger. Physicians cannot deny the magnitude
of the multiple chronic illnesses. There is a thin line of
100 I
: clear clinical judgement between waiting and an avoidance j
; j
situation based on denial. The psychiatrist reaches the
point of denial of conveniently spacing out the sessions
when no new alternative is available rather than continuing
to give support and comfort to the patient (Short & Wilson,
1969).
I
j CHAPTER V i
i :
i |
LITERATURE REVIEW OF REHABILITATION j
i The "quality" of life style of patients on mainte- |
i |
inance dialysis is a major concern (Abram, 1969b). j
Rehabilitation becomes a primary goal once dialysis has
begun (Curtis et al., 1969). Rehabilitation is a primary
i ;
|goal so that the patient can return to work and enjoy
[leisure time with his family (Rae et al., 1968).
j Most centers regard rehabilitation as paramount for
two reasons: (a) the unrehabilitated patient responds
poorly to treatment since a lack of activity and involve
ment in his family and social life leads to dietary
indiscretions, depression, anxiety, and other psychosomatic
[disturbances, and (b) the economic problems of long-term
Idialysis are more expensive for a patient who is not
supporting himself or his family (Comty, 1969).
! Most published studies limit reported rehabilita- I
|tion information to employment. However, rehabilitation of :
hemodialysis patients involves resumption, as much as
realistically possible, of the previous life style. There- |
j i
i
fore, this study subdivides rehabilitation into the j
I
jfollowing three areas: (a) work, (b) sexual functioning, j
101
r ‘. '. . . " 1 0 2 ]
and (c) physical activity and social involvement.
; }
i
; I
;Work Rehabilitation
Work rehabilitation is a necessary goal with
jdialysis patients for overall well-being. Continued
t
I schooling or employment is necessary to give the patient
| some purpose to his activities and to provide a challenge
. and stimulus to achieve complete rehabilitation (Brown
et al., 1962). j
1
]
Dialysis creates difficulties in job rehabilita- [
tion. Dialysis employees have greater absenteeism due to J
periodic, unpredictable transient ill-health or complica- j
j
tions such as shunt revisions requiring hospital treatment.
Physical restrictions for cannula protection may make j
previous employment involving manual activity prohibitive
and require the patient to undergo job retraining before
working again. The time away from the job due to dialysis
| requirements may necessitate a decrease in job responsibil-
i
! ity (Wright et al., 1967). Ill-health may restrict the
j
! patient to part-time employment.
Education and employment background can affect job
rehabilitation. Unemployment is higher following dialysis
for patients who previously worked in heavy industry and .
require job retraining (Goodey & Kelley, 1967). Patients
jwith college training have less difficulty in returning to
|work in the same field or in a new profession (Meldrum
L _
103
let al., 1968). College educated patients may have less job j
|problems for two reasons: (a) professional occupations I
| allow greater flexibility of hours so that absenteeism for
transient ill-health would not be as crucial to job
survival, and (b) professional occupations are more seden
tary and would be less affected by cannula requirements.
• If dialysis requires a residence relocation, patients with
out college training have been found to have more diffi
culty finding employment (Meldrum et al., 1968). j
The severity of uremia prior to initiating dialysis
is a major determinant of work rehabilitation. Unless j
I
dialysis is begun when the patient is still free from j
I
irreversible complications, the chances of effective
rehabilitation is reduced and the prolonged life of poor
quality (Hegstrom et al., 1962). Patients who are rapidly
admitted to dialysis following onset of chronic uremia
I symptoms can frequently return to work within a matter of
weeks (Hampers & Schupak, 1967). Patients with a protractec
illness are more difficult to rehabilitate. They may have
severe loss of muscle mass and strength (Curtis et al.,
1969; Hampers & Schupak, 1967). They may require several
months of dialysis before being able to resume work.
Severe peripheral neuropathy is a medical factor
aversely affecting work rehabilitation. Various studies
report disabling neuropathy in unemployed patients
(Gonzalez et al., 1963; Hegstrom et al; 1962; Lindholm
et al., 1963; and Murray et al., 1964). It will be noted ;
that these studies were earlier publications when uremic
:patients were not treated with dialysis as rapidly as they
I
]
|are today. The incidence of disabling neuropathy prevent-
!ing a return to work should be less prevalent for patients
Sin this contemporary study. However, it is expected that
patients found in this study with severe neuropathy would
probably only attain half-time employment at best.
Psychological factors also affect job rehabilita-
i
tion. Patients who used physical symptoms in the past for |
secondary gain would probably show inadequate rehabilita
tion (Sand et al., 1966).
j
Studies reported rehabilitation hampered by
maladaptive patient attitudes. One woman with six children
regressed to almost no activity and sat around most of the
time with her shades drawn (Brand & Komorita, 1966).
; Rehabilitation is difficult for patients who lose their
! initiative and interest in returning to work or school
! (Brown et al., 1962; Curtis, 1968). One man who was
|occupationally inactive had idealistic shopowner plans
(Brand & Komorita, 1966). Patients need to be helped to
recognize that idealistic dreams or inactivity are not
appropriate ways to adapt (Brand & Komorita, 1966).
One study related rehabilitation to personality
type observed in male patients in a hospital for veterans.
The conformist type, who is characterized by many passive
; and dependent traits, may accept the patient role too well >
and is less likely than other patients to look for work.
| The highly individualistic and independent masculine type
i
j with a history of occasional conflicts with authority
| chooses action in handling anxiety. His resistance to
| acceptance of his illness may severely interfere with
treatment regime; but his resistance contributes to his
rehabilitation since he maintains his former work and
social patterns (Norris, 1968).
I
Following is a literature review of male and femalej
work rehabilitation. The literature is incompletely
reported. However, with improved medical treatment, a j
higher percentage of rehabilitation is found in more recentj
studies.
One of the first published reports in 1960 on two
center patients who had received approximately 10 weeks of
| dialysis disclosed that neither was strong enough to work
| full-time (Schribner et al., 1960).
|
| Of eight patients treated over two years, one died
i
and five were rehabilitated occupationally (Hegstrom
et al., 1962). One patient was able to do light activity
but was not motivated to work since he received total
disability. The last patient was disabled by severe
neuropathy and confined to a wheelchair.
Lindholm et al. (1963), reporting on seven center
patients, stated that prior to dialysis none were able to
work even half-time. Six of the seven patients attained
' full rehabilitation in which they were able to resume
i almost full employment and engage in their usual hobbies
I
! and recreation.
j
i
| Shaw et al. (1965) reported that of 20 center
i
j patients on a low protein diet for over five months, four
; died, five resumed working or housewife activities, and 11
had more or less restricted lives free of uremic symptoms.
A four-year coverage of 23 patients at the Seattle
Artificial Kidney Center disclosed that 12 were working
36-50 hours per week and 7 were working 16-24 hours per
week (Haviland, 1965).
Pendras and Erickson (1966) reported job rehabili
tation results for 18 out of 22 center patients with a
! total of 40 patient years of treatment. Thirteen were
working 32-50 hours and five were working 16-24 hours.
Three patients were in the process of retraining. One
jpatient was bedridden for a year prior to death.
In a group of patients in a community hospital with
|a liberal selection policy, 12 out of 26 patients achieved
employment rehabilitation (Schupak et al., 1967).
Goodey and Kelley (1967) in England reported that
only 2 out of 20 center patients were working full-time
while one was working part-time. They attributed this low
rehabilitation incidence to daytime dialysis, the long
distance to the treatment center, and to previous, now
107 i
inappropriate, employment in heavy industry. j
I
Of 24 Veterans Administration center patients, 16 j
; returned to work, three failed to meet projected employment
i
|potential, and five were unemployed due to job market
|circumstances beyond their control.
j
; Curtis et al. (1969), reporting on 32 patients in
iLondon, stated that 18 out of 19 men and 5 out of 6 previ
ously working women were employed. The unemployed male had
difficulty finding work in his highly specialized profes- j
sion. They attributed the work rehabilitation success to: i
j
(a) night dialysis, (b) previous employment in occupations |
requiring a minimum of physical activity, and (c) the
available job market and facilities for retraining in
London.
A report on home patients disclosed that all 12
patients living near the treatment center were employed
i
;(Shapiro et al., 1968). Of 25 satellite patients, 19 were
i
employed full-time, 4 were employed half-time, and one
|retired patient was employed one-fourth time. Most returnee
to preillness activities within six weeks of starting
dialysis. Only five had to change jobs.
Of 21 home patients living an average of 230 miles
from the training center, 14 were working full-time,
4 part-time, and 3 were unemployed (Rae et al., 1968). Two
of the unemployed were well enough to work while the third
was awaiting vocational retraining.
~ ’ 108 !
A comprehensive survey of 689, or 81%, of the
i !
. estimated dialysis patients in the United States in the i
! latter half of 1967 disclosed that 46% of the males were
I
j employed, 34% were unemployed, and 13% were students, in
i
| retraining, or retired (Katz & Procter, 1969). They noted
!
i that other published reports give higher employment rates
| than these figures obtained directly from the patients.
Katz and Procter found the following factors related to j
employment: (a) the unemployed male was more likely to be j
younger, (b) dialysis patients had a high rate of work |
absenteeism due to their medical condition and dialysis,
(c) changes of occupation occurred primarily in the blue j
collar occupations, (d) patients with college training had j
a significantly higher employment rate, and (e) employment
status was associated with good state of health.
Sexual Functioning
!
j The return to preillness sexual potency varies
I
| among dialysis patients. Katz and Procter (1969) gathered
I data from 78% of the estimated dialysis centers and 81% of
the estimated dialysis patients in the United States in
late 1967. They found that 20% of the males reported
impotence prior to dialysis treatment (Katz & Procter,
!1969). Seventeen per cent of the patients indicated an
I impotency problem to staff members following dialysis.
j However, Katz and Procter felt that nonresponse to this
109 |
type of question made this frequency a low estimation of
the problem among dialysis patients.
| Sexual problems of dialysis patients was covered
previously in Chapter II. However, the decline in sexual
behavior may become a strong psychological stress,
!especially in male patients, aversely affecting total
rehabilitation.
T he im p o t e n t o r s e x u a l l y i n a d e q u a t e d i a l y s i s
!
patient may experience a change in body image or a loss of j
i
masculinity. This could interfere with his functioning in
social or work areas. !
I
In paraplegics, sexual dysfunction has resulted in i
a sense of complete inadequacy (Berger & Garrett, 1952). j
Maintenance of sexual function in paraplegia has been shown
to be important to rehabilitation and to a sense of well
being (Talbot, 1955). Potent paraplegics were more inter
ested in vocational training (Lindner, 1953).
j The sexual performance of the dialysis patient may
j
j be aversely affected by a decline of interest in the
spouse. The patient's weight loss, observable cannula, and
bone and joint pain have led to a decreased sexual desire
in some spouses (Wright et al., 1966). Some spouses have a
decreased sexual desire due to this changed body image of
the patient (Wright et al., 1966).
Sexual functioning of dialysis patients varies
greatly among treatment centers. Either there are subtle
110 :
t r e a t m e n t d i f f e r e n c e s a f f e c t i n g p o t e n c y o r , m o re p r o b a b l y , :
t h e s t a f f i s c o m m u n ic a tin g e x p e c t a t i o n a l c u e s t o t h e j
i p a t i e n t . I f t h e s t a f f c o m m u n ic a te s p e s s im is m a b o u t r e t u r n
i n g p o t e n c y l e v e l s , t h e p a t i e n t s w o u ld p r o b a b ly h a v e
s i m i l a r e x p e c t a t i o n s .
j
i P h y s i c a l A c t i v i t y a n d S o c i a l I n v o lv e m e n t
Following dialysis, social involvement is necessary
i
for a full sense of well-being. Patients frequently have j
to withdraw from strenuous athletic activities to prevent
j
tr a u m a o r i n j u r y t o t h e i r c a n n u l a s . T h ey s o m e tim e s r e s i g n |
i
from social clubs or officer positions in social or ;
b u s i n e s s o r g a n i z a t i o n s . T h e l o s s o f m e m b e r s h ip i n g r o u p s I
j
can be a source of psychological stress to dialysis 1
patients (Wright et al., 1966).
Dialysis patients have a marked reduction in
recreational and social activities while on dialysis
; compared to preillness activities (Katz & Procter, 1969).
| Even though their activities decreased, their relationships
i
i w i t h f r i e n d s a n d f a m i l y a p p e a r e d n o t t o b e e x t e n s i v e l y
a f f e c t e d b y d i a l y s i s (K a tz & P r o c t e r , 1969).
Some patients relocate to a new community for
dialysis (Wright et al., 1966). They may respond to the
shift in relocation pathologically. One case was reported
where a patient who moved failed to relocate emotionally
and adjust to the new community (Meldrum et al., 1968).
; He made few friends and often returned home ignoring his
; scheduled dialyses. A divorce finally culminated in a foodj
! binge at his old residence in which he developed cardiac
arrest and died.
Rehabilitation Variables
| Sexual potency of home patients would probably be
!
related to many factors such as: residual kidney function,
self-image, physical and psychological well-being, and j
attractiveness of the partner. This study will use sexual
functioning as both a predictor and criterion variable. |
An effort will be made to uncover factors affecting j
decreased potency. To this end questions on the Staff j
Questionnaire will try to assess whether patients from
different treatment centers are given differential expec
tations affecting behavior.
If the work on paraplegics generalizes to dialysis
j patients, then sexual potency may positively relate to work
i
: or social rehabilitation. Therefore, sexual potency will
|
also be used as a predictor variable of these two areas.
Other factors that may relate to work rehabilita
tion include: education, occupational classification,
duration of illness before dialysis, and presence of
disabling neuropathy.
Social involvement will be roughly measured by
subjective statements from the patient and spouse.
!Variables affecting social rehabilitation
!this time but will probably be related to
being.
112 |
are unknown at
physical well-
CHAPTER VI
REVIEW OF SELECTION CRITERIA LITERATURE
As stated in Chapter I, systematic investigation of
the validity of selection variables has been a neglected
area of hemodialysis research. The selection of patients
for dialysis raises social, medical, legal, and ethical
issues since rejection means death.
In the early sixties, when dialysis treatment was
beginning to be inaugurated in medical centers, criteria
for selection of patients such as: age, intellectual
capacity, emotional stability, etc., were arbitrary and
rigid.
Curtis in London (1969) admits that limited facili-
|ties result in arbitrary patient selection since there is
|no abstract principle by which to judge life. Generally
speaking, centers presently are more flexible in the
selection of patients and have broadened the acceptable
range of nonmedical criteria.
Although some of these nonmedical criteria have an
apparent face validity, no research has ever been under
taken to determine their actual validity to hemodialysis
adaptation. By exploring the relationships of popular
113
' 114
selection criteria to objective criteria of adaptation, it |
I
i
is hoped that this study will shed some additional materialj
of the validity of these current selection variables.
This chapter will systematically review published
selection criteria. Unfortunately, many centers have not
|published their selection procedures. Other centers define
their criteria in vague terms which could allow "worth to
society" or other personal prejudices to unconsciously bias j
patient selection. Rubini and Goldman (1968) stated that j
the criteria for making selection decisions should be as j
lucid and objective as possible. !
In 1963 the Seattle Artificial Kidney Center had j
i
one of the earliest and socially severest proposals for i
patient selection. The following selection criteria were
included: (a) stable, emotionally mature adult under the
age of 45, (b) absence of long-standing hypertension and
permanent complications therefrom, (c) demonstrated will
ingness to cooperate especially with dietary restrictions,
| (d) stable or slowly deteriorating renal function since
|residual function helps treatment, and (e) exclusion thus
far of children and yoking adults who are not potentially
self-supporting. If the candidate passed these criteria
reviewed by a Medical Advisory Committee of physicians,
then a final selection was made by a mixed lay-medical
committee who evaluated candidates on sociological and
economic factors (Lindholm et al., 1963; Murray, Tu,
Albers, Burnell & Schribner, 1962; Schribner, 1963).
j
In contrast, one of the most liberal selection
i procedures was simultaneously proposed in 1963. Barber
j et al. (1963) felt that only renal insufficiency severe
|
| enough to preclude life without chronic dialysis should be
i
|the sole criterion for admission when space was available.
; They made no attempt to select patients on the basis of
age, type of disease, or presence or absence of complica
tions . They did not see psychiatric factors as an initial j
|
deterrent since many patients were more or less psychotic j
until treatment. However, they felt treatment should be
discontinued when the patient is unable or unwilling to
cooperate after his chemical balance is restored.
j
Retan and Lewis (1966) employed no selection
system. Of the eight patients, three developed severe
psychotic disturbances. They concluded that patient selec-
;tion for motivation, intelligence, emotional stability, and
; rehabilitation potential appeared to be necessary to obtain
sufficient cooperation for long-term success.
! Esmond, Strauch, Zapata and Hernandez (1967)
J reported good results without selection procedures of
i
dialysis candidates. Since a significant percentage of
unselected patients who were dying from uremia could be
rehabilitated, they felt that the exclusion of "poor
candidates" by a committee is no longer indicated.
116
| William Kolff, the inventor of the artificial
kidney, felt that committees should be formed to establish
I |
'possibilities for more treatment and not to exclude certain I
(patients. He questioned the principle that social standing
Ishould determine selection, and asked, "Do we allow
patients to be treated with dialysis only when they are
i i
married, have a good income, and give to the Community
, !
|Chest?" (Kolff, 1964). j
! j
j Schreiner and Maher (1965) stated that many ethical j
(questions surround the selection of patients. They asked j
|if selection should be only by medical criteria or if i
j ;
'selection should embrace social questions such as "value" ;
or contribution to society or the burden the patient leaves j
behind when he dies. Furthermore, who makes the decisions
(about the value and productivity of a person?
Sanders and Dukeminier (1968) raised the issue of j
(the violation of constitutional guarantees of equal protec- j
(tion and due process when selection committees exist.
(Regarding the Seattle selection committee, they felt that
the committee's deliberations are muddled by prejudices and !
(mindless cliches. For example, they related how one member '
j |
(thought people of good character, indicated by a record of !
ipublic service such as scout leader or Sunday school !
; i
(teacher, should be saved. Sanders and Dukeminier concluded (
i (
that "Justice requires selection be made by a fairer method j
(than unbridled consciences, the built-in biases, and the j
117 |
fantasies of omnipotence of a secret committee." j
; i
Schribner felt that a civilian board was necessary j
to weed out applicants as a means of representing the
I
jcommunity and assuring that the choice is made objectively
without pressure (Robbins & Robbins, 1967). However, Wilson
1(1967) was against lay panels since they have no personal
knowledge of the patient and have to base their judgement
on medical and social reports.
By 1967 the ethics of a lay selection committee was
a more peripheral issue in selection procedures. A 1967 |
j
review, supported by the United States Public Health !
Service, of 11 dialysis centers disclosed that only two j
centers were selecting patients through the aid of an
advisory lay committee. The majority of the centers, or
eight, used only physicians on the selection committee.
The remaining center had a mixed committee of three physi
cians plus a master social worker (Abram, 1968).
| The Katz and Procter (1969) study of 93, or 78%, of
|the dialysis centers in 1967 disclosed only eight centers
using a lay advisory selection committee which did not vote
in the selection. Primarily, physicians voted on the
selection of patients. Facility directors voted in 73
centers, staff physicians voted in 64 centers, and referring
physicians voted in 11 centers. Paramedical personnel
(staff nurses, social workers, psychiatrists, and psycholo
gists) voted on the selection of patients in less than 20
' “ ‘ ' " 118 |
centers.
Various centers include a psychological evaluation ;
I of the candidate and/or his family as part of the selection
procedure (Brown et al., 1962; Gombos et al., 1964;
Haviland, 1965; McLeod, Mandin, Davidman, Ulan & Lakey,
I 1966; Meldrum et al., 1968; Nabarro, 1967; Sand et al.,
! 1966).
i
Centers obtain this psychological information
differently. At one center, the psychiatrist reported on
the patient and the wife while a master social worker
obtained socioeconomic data (Meldrum et al., 1968). At
another center the patient was seen by a psychologist, j
psychiatrist, and social worker who obtained financial
screening data (Haviland, 1965). Another center used a j
i
single interview by a psychiatrist coupled with a test
battery including the WAIS, MMPI, Rorschach and TAT admin
istered by a clinical psychologist (Sand et al., 1966).
| The Queen Elizabeth Hospital in Adelaide, South
Africa used psychiatric and unspecified psychological
testing in patient selection. This information can uncover
specific current problems and help the staff to understand
and support the patient as well as delineate his personal
ity structure and the dynamics of family life as it affects
the patient (Cramond et al., 1968).
j The Katz and Procter study (1969) had the dialysis
I
centers rate a list of 17 selection criteria. Of 87
119 :
centers reporting, the most frequently used criteria and !
the percentage of the centers using them are as follows: j
(a) willingness to cooperate in treatment regime, 86%,
I (b) medical suitability or good prognosis with dialysis,
j
j 797o, (c) absence of disabling disease other than of renal
i
I function, 69%, (d) intelligence as related to understanding
treatment, 34%, (e) likelihood of vocational rehabilita
tion, 32%, (f) age, 29%, (g) primacy of application for
available vacancy, 26%, and (h) psychiatric evaluation,
25%. |
I
Such factors as: congeniality of the patient, ;
i
economic burdens of dependents if not selected, demon- j
strated social worth, and future social contribution, which!
have overtones of moral judgement and middle-class bias, j
I
were considered of minor importance by the majority of the
centers (Katz & Procter, 1969). However, one-fifth to
ione-third of the centers rated them as important,
iDifferent sized facilities had only minor differences in
i
the perception and application of selection criteria.
Psychiatric evaluations were more frequently employed in
the larger centers (Katz & Procter, 1969).
Conditions which definitely excluded selection of a
patient in the 87 centers include the following: (a)
mental deficiency, 68%, (b) poor family environment, 29%,
(c) criminal record, 25%, (d) indigency, 21%, (e) poor
employment record, 20%, (f) lack of transportation, 17%,
120 ;
and (g) nonresident of the state, 17%.
Although sex was not reported as an important
icriterion, there were only 173 women in the sample of 689
patients. Katz and Procter (1969) asked if this imbalanced
sex ratio reflected: a greater incidence of chronic renal
;failure among males, differential rates of medical treat
ment referral, preference for patients who can be vocation
ally rehabilitated, or other factors. Since sex was ranked
as an unimportant criterion, this result may mean that the j
other given criteria ranks are not representative of the j
true weights factors play in actual selection (Katz & j
Procter, 1969). j
Abram (1969b) conducted a smaller study of selec- I
tion criteria of 14 centers. His findings were somewhat
similar to the Katz and Procter study. The selection
criteria and number of the 14 centers using them were as
follows: (a) no other debilitating illness, 11 centers,
;(b) age between 15 and 60 years, 8 centers, (c) motivation
|and cooperation, 7 centers, (d) potential for rehabilita
tion, 6 centers, (e) emotional stability, 3 centers, (f)
distance from the center, 2 centers, (g) productive
citizen, 2 centers, (h) ingelligence, 2 centers, (i) finan
cial resources, 2 centers, (j) suitability for home
|dialysis, 1 center, and (k) resident of the state,
|1 center.
i
L
121 !
Reported General Selection Criteria
Following are most of the published nonmedical
criteria either used in selection or viewed as a necessary
|selection requirement.
j Maximum age. An upper age limit of 45 years has
jbeen frequently proposed (Hampers & Merrill, 1966; Lindholm
I
et al., 1963; Murray et al., 1962; Schribner, 1963). In
1967 Schribner was reported as dropping the maximum age
limit to 40 years (Robbins & Robbins, 1967). One center I
rejected applicants over 35 years of age (Hegstrom et al.,
I
1962). j
Recent literature has reported a wider age range of j
patient acceptance, including: 15 to 50 years (Curtis |
et al., 1969), 15 to 65 years (Comty, 1969), 17 to 50 years
(Haviland, 1965), and 26 to 62 years (Barber et al., 1963).
One center, with patients varying from 24 to 52 years of
|age, found that patients in the 20-to-39-year age range did
better medically, socially, vocationally, and rehabilita-
tionally than patients over 40 years of age (Meldrum et al.,
1968).
Intelligence. Intelligence is considered an impor
tant selection criterion (Davidson & Pendras, 1967; Gombos
et al., 1964; Hampers & Merrill, 1966; Retan & Lewis, 1966;
|Sand et al., 1966).
Hampers and Merrill (1966) felt that the patient
r ~ 122
must have sufficient understanding and maturity to accept i
the responsibility of self-care. Gombos et al. (1964) felt|
that the selected patient must be free from intellectual
I
deterioration.
Others have stated that average or above-average
| intelligence is necessary for self-care or for selection to
| r
home dialysis (Davidson & Pendras, 1967; Gombos et al.,
1964; Sand et al., 1966). Sand et al. (1966) found the
I
higher intelligent patient to be better adaptive. J
Crammond et al. (1968) assessed intelligence but j
j
did not state if it was critical to selection.
|
Cooperation. Cooperation with self-care of the i
medical regime, especially the dietary restrictions, is
considered an essential selection criterion by most centers
(Hampers et al., 1965; Lindholm et al., 1963; McLeod et al.,
:1966; Murray et al., 1964; Schribner, 1963; Schupak et al.,
1967; Schupak & Merrill, 1965).
j
Desire for treatment, motivation, and adaptive
I
ability are also viewed as important factors of cooperation
in selecting patients (Comty, 1969; McLeod et al., 1966;
Meldrum et al., 1968; Schupak et al., 1967).
Some centers felt that demonstrated willingness to
cooperate is an important selection criterion (Comty, 1969;
Haviland, 1965; Hayes, Wilson & Robinson, 1966). Hayes
et al. (1966) stated that the demonstrated ability of a
! 123 !
! j
icandidate to adhere to a rigid therapeutic regime is the
i i
jmost reliable index of his ability to adapt to the continued
!demands of dialysis.
: i
Retan and Lewis (1966) felt that motivation, j
;intelligence, emotional stability, and rehabilitation j
ipotential are important selection factors in obtaining the
jdegree of cooperation necessary for long-term success. i
Cooperation is essential for treatment success. i
Schribner, Fergus, Boen and Thomas (1965) stated, "It now
i
appears that picking the cooperative patient is a far more j
| 1
|important criterion of selection for chronic dialysis than
|the other needlessly rigid criteria originally proposed by
lour group."
i
Emotional maturity and stability. Emotional
stability or emotional maturity is a common selection
i i
criterion (Gombos et al., 1964; Gonzalez et al., 1963; 1
Hampers Sc Merrill, 1966; Haviland, 1965; Lindholm et al., I
1963; LoCicero et al., 1967; Meldrum et al., 1968; Retan
Sc Lewis, 1966; Rubini S c Goldman, 1968; Schribner, 1963). j
A survey of centers confirmed the use of psychological j
Istability as a major selection criterion (Comty, 1969). j
! i
! i
Evidence of overt or latent emotional instability i
i !
is considered a contraindication for selection (Brown
j
|et al., 1962). A patient with a history of serious
124 ;
psychiatric disturbances or illness is considered unsuit
able for selection since intelligent cooperation is needed j
; j
|regarding the diet and cannula care (Comty, 1969; McLeod,
1966).
| Family support. The stability of the marriage or
I family support is considered an essential selection
criterion (Brown et al., 1962; Cramond et al., 1968;
Davidson & Pendras, 1967; Enlow & Freed, 1967; Gombos
I
I
et al., 1964; Meldrum et al., 1968; Schupak et al., 1967). |
i
One study evaluated the emotional stability of the j
family since it has a considerable influence on the
patient?s reaction to dialysis. Cramond et al. (1968)
stated that the staff cannot completely understand and
support the patient without an awareness of the immediate
family and its relationships.
Where a liberal selection policy was used in choos-
i
jing patients for dialysis at a municipal hospital, it was
found that family support was important in patient care and
rehabilitation (Schupak et al., 1967). Enelow and Freed
(1967) concurred that the patient with interpersonal and
social ties has a better prognosis.
Family support is one of the few selection criteria
s
|generally viewed as crucial to successful patient adapta-
i
jtion. To handle the various continuing stresses and
hardships of hemodialysis, patients need strong emotional
125 j
support from family members. j
Rehabilitation potential. The potential to be
i
[self-supporting and rehabilitated is a major criterion at
I
many centers (Haviland, 1965; Lindholm et al., 1963; Murray
et al., 1964; Retan & Lewis, 1966; Schribner, 1963).
| Some centers discussed rehabilitation selection
j
icriteria in job terms. Parsons (1967) stated that gainful
i
employment in a well chosen occupation is necessary to [
!
achieve the best results. Another center felt that adjust- j
!
ment to society included economic success and the relative j
reobtainment of the preillness standard of living (Meldrum
j
et al., 1968). Schupak and Merrill (1965) felt that j
patients should be selected on the basis of likelihood of
returning to a useful role in society.
Other centers placed rehabilitation selection
criteria in a societal context. The New England Journal of
Medicine (1967) stated that since an accepted patient
jcannot be dropped, it is essential that the patient with
[the best chance of rehabilitation (social, vocational, and
psychological as well as medical) be selected to make
optimum use of a scarce resource. Wilson (1967) vaguely
stated that the individual chosen should be the one that
would benefit most and that the greatest good would thereby
be achieved.
126 |
Reported Sociological Selection Criteria
To a lesser extent, treatment centers weigh socio-
; i
logical, financial, or geographical factors in the selec-
I
jtion of patients. Some of the selection considerations
found in the literature are presented next.
i
i Value to the community. Two studies reported that
community value was assessed in selecting patients
(Haviland, 1965; Schribner, 1963). I
|
i
Financial support. Patients are selected on the
basis of personal financial ability to defray dialysis j
I
costs (Haviland, 1965). j
Number of dependents. Patients are selected on the j
|
basis of family members they would leave behind (Meldrum
et al., 1968; Murray, 1964). Meldrum et al. (1968) found
that patients with children had a better medical, social,
;and vocational adjustment. They felt that small children
|served as an increased burden which pressured the patient
I
|and increased his motivation.
Economic status of survivors. Murray et al. (1962)
reported on the use of this selection criterion. Further
more, socioeconomic forces may be the limiting factor in
instituting center or home dialysis (Hampers et al., 1965;
Hampers & Merrill, 1966).
| A survey of selection criteria at centers disclosed
127 |
that selection of suitable candidates depended on facility j
. j
availability and financial support. There was a preference;
; i
|for patients who were: (a) highly motivated with good
|
prospects of rehabilitation, (b) married, and (c) had
children (Comty, 1969).
i
Residence requirements. One center selected candi
dates by geographic proximity (Murray et al., 1964). One
j
center required candidates to have six months' residence inj
I
I
the area (Haviland, 1965). |
Exclusion of children. Children under the age of j
three have been dialyzed (Williams, Hargest & Wohltmann, j
I
1969). However, few centers accept children, since it is j
generally felt that children do not have the capability to
cope with the mental stress of months on dialysis
(Salisbury & Mutter, 1968).
In the few cases where children have been accepted
|on dialysis, the results have been poor. They often
|exhibit arrestment of physical development. They can
|become psychologically maladaptive.
One study described the gradual mental deteriora
tion of a nine-year-old girl during eight months of
dialysis (Salisbury & Mutter, 1968). She regressed from a
bright active child to an untidy, withdrawn, self-destruc-
tive, passive, demanding, clinging, and argumentative child
prior to her death following transplant.
; " ' ' 128
Another study described problems or death in all
five teenagers accepted to dialysis (Schupak et al., 1967). j
!One teenager died after four months because of an inability
i
|to cooperate. One had not grown in height nor weight and
|tended to experience dialysis disequilibrium. Another had
'pericardial effusion requiring hospitalization. Another
had less supportive parents and therefore more difficulty
with the diet and shunt care.
Salisbury and Mutter (1968) stated that the
i
increased problems with dialyzed children regarding diet,
attempts to remove the shunt, and passive or demanding ward!
behavior appear to corroborate the belief that children are|
not suitable. Schupak et al. (1967) were convinced that
children, more so than adults, need strong, intelligent
family support; and that lack of good family support should
serve as a deterrent to acceptance.
jReported Psychological Selection Criteria
I A few selection articles have alluded to psycholog
ical selection criteria. Selection of patients has involved
an evaluation of the patient’s acceptance of dependency and
aggression (De-Nour et al., 1968). De-Nour et al. felt
that a patient who accepts dependency and aggression might
adapt to hemodialysis without extreme mobilization of
|defenses, ego constriction, or psychiatric symptoms.
| Centers have evaluated candidates for ego strength
129 ;
(Cramond et al., 1968; Meldrum et al., 1968). Ego strength;
was assessed by observing how the patient copes with his
life situation (Meldrum et al., 1968). One center assessed
|
jthe patient's strengths and resources and preferred
i
jpatterns of ego defense (Cramond et al., 1968).
One study attempting to predict patient success
|found that better adaptive patients had a less defensive
attitude on interviews and tests about admitting anxiety or
emotional difficulties (Sand et al., 1966). More adaptive j
patients also had a prominence of depression over somatiz- !
|
ing defenses (Sand et al., 1966).
j
Norris (1968) felt that only extreme masculinity or;
I
extreme conformity of male candidates, which would foster j
extreme, maladaptive independent or dependent behavior,
would preclude the candidate from selection.
Criteria Specific to Home Dialysis
j
Mechanical ability. Shaldon (1968a) found reason
able mechanical aptitude to be more advantageous for home
dialysis success than intelligence or previous medical or
paramedical experience.
Indenendence. Independence in a patient is consid
ered important for training for home dialysis (Davidson &
Pendras, 1967). On the negative side, if a patient is
unable to accept his dependency and has a low frustration
130 j
tolerance for his aggression, De-Nour et al. (1968) have
recommended the patient for home dialysis instead of center |
dialysis.
Family support and socioeconomic considerations.
Wood (1969) stated that the home patient should have a
!capable spouse or relative willing to undertake the respon
sibility of working with the machine. Wood also felt that
: i
the ideal home patient should be in his own home, prefer- j
ably a house, have a job he can retain after many absences, j
and be a useful member of society. ;
i
Space. Shaldon (1968b) accepted patients on a j
first come basis with the minimum requirement of 80 square ;
feet of room, and with running water, electricity, and a j
telephone.
Arguments Against Proposed
Selection Criteria
| Dialysis results of selected patients do not
|support the arbitrary selection criteria used. Shaldon
(1968b) in England accepted patients rejected by other
facilities because of illness, age, or lack of emotional
stability. The rejected patients were no less successful
than the conventionally suitable patients.
This section will present published arguments
against various selection criteria employed.
131 |
Age. Except for a social worth judgement as to j
|
future productivity, what is the validity of an arbitrary j
I age cutoff in terms of program adaptation?
i
Sanders and Dukeminier (1968) note that most hemo-
|dialysis centers are unwilling to dialyze patients over 50
I years of age. However, patients in the seventh and eighth
|decades of life have responded well to dialysis (Schupak
et al., 1967).
A study of survival rates of 302 patients, or one-
third of the estimated dialysis population, disclosed that |
!
the survival rate of the group over 45 years of age was not I
statistically significantly different from the survival j
rate of the group of patients under 45 years of age (Lewis,j
i
Foster, de la Puente & Scurlock, 1969). [
I
Older patients adapt well to a strict regime
(Comty, 1969). Patients over 50 years of age tolerate
i
dialysis as well as younger patients (Figueroa, 1969).
j Figueroa (1969) had satisfactory results with five out of
i
seven patients over 50 years of age. There is an increased
I risk of complicating pathology, especially cardiac prob
lems, in older patients (Comty, 1969). However, most of
the problems in older patients are related to illnesses
common to older people (Figueroa, 1969).
! Retan and Lewis (1966) concluded that the results
do not support a continued arbitrary selection of patients
|based on an age criterion.
132 j
Intelligence. Currently, hemodialysis centers are j
!
admittedly biased in selecting patients on the basis of j
I intelligence comparisons. What is the amount of sufficient
j
! intelligence required to understand and carry through on
I treatment requirements? Various studies indicated that it
jmay be more minimal than generally assumed.
The degree of intelligence necessary for home
dialysis is not great (Hampers et al., 1965). A lack of
patient intelligence has been compensated for on home
dialysis by patient motivation and thorough dialysis train- j
ing (Eschbach et al., 1967). j
Shaldon (1968b) obtained successful home dialysis j
|
results with patients rejected at other centers for not j
j
meeting intelligence requirements. Shaldon believed that j
reasonable mechanical aptitude is more advantageous than
intellectual achievements for home dialysis.
Dialysis requires intelligent cooperation regarding
|diet and cannula care, but a high degree of intellectual
jattainment is not necessary (Comty, 1969). Cases of
diminished intellectual ability have the capacity to do
well on a center program and become therapeutically rehabil
itated and self-supporting (Schupak et al., 1967). One
center patient with an intelligence quotient of 85
continued working and had one of the lowest incidences of
cannula problems (Schupak et al., 1967).
_ . . _ 133
i
! Although Sand et al. (1966) found that better adap- |
tive patients were higher in intelligence, confounding of
I i
'subjective criterion variables could have facilitated this
result. Sand et al. (1966) attempted to validate pretreat-
; I
:ment predictions of patients to later medical ratings of
adjustment. Predictions of newly selected patients were
made on the basis of a single psychiatric interview coupled i
jwith a test battery including the WAIS, MMPI, Rorschach,
| :
jand TAT. Ratings of cooperation, emotional adjustment, and i
! recommendations of similar type patients were obtained from ;
i ;
jthe staff consisting of nurses, nurses aides, and physi-
Icians. Patients were ranked into categories of "superior," j
i"adequate," or "poor" in terms of adjustment and coopera-
' i
tion. Significant correlations were found for pretreatment
! i
predictions and ratings obtained two years later of cooper-
i
jation and adjustment. However, these results may be biased ;
in the use of subjective adaptation criteria which could
reflect the rater's personal reaction to the patient.
Furthermore, a general consensus of opinion about a patient ;
I !
could have emerged from frequent staff meetings.
; i
; The minimum functioning level of intelligence for j
|successful adaptation has not been established at this j
time. I
| |
! i
j |
Emotional maturity and stability. For selection !
i
purposes, patients' emotional maturity and stability have
' 134 !
!been evaluated by: (a) behavior and treatment cooperation j
during the waiting period for acceptance to the hemodialy-
|sis program, (b) psychological and psychiatric evaluations
!including interviews and tests, and (c) social data includ-
j
|ing occupational or school adjustments, interpersonal
|interactions, reported personality characteristics, and
reactions to previous illnesses (Brown et al., 1962; Gombos
i
et al., 1964; Meldrum et al., 1968; Sand et al., 1966; |
Schreiner & Maher, 1961; Schupak & Merrill, 1965). i
|
Although past life style and ways of coping with j
illness could help in predicting future adaptation and in
deriving a rating on emotional maturity, it can be seen j
that emotional maturity has been indirectly and nebulously |
i
evaluated.
The relationship of this criterion to patient
adaptation on hemodialysis has not been proven. Patients
evaluated as poor risks have shown exceptional strength and
I coping ability while other seemingly emotionally stable
patients have had psychotic-like disturbances on the
program. Shaldon (1968b) found patients successful on home
dialysis who had been rejected at other facilities for not
meeting the emotional stability criterion.
It is not easy for psychiatrists or social workers
to predict who has or will develop qualities for adjustment
to the machine (Sanders & Dukeminier, 1968). The ordi-
jnarily difficult assessment of psychologically related
135
selection criteria is further complicated by the temporary
personality changes accompanying chronic renal failure
(Katz & Procter, 1969). The physical condition of uremia
iinterferes with: interviewing, testing, understanding the
personality, and in assessing pretreatment personality to
i
predict posttreatment personality (Enelow & Freed, 1967).
j
The physician who has been treating the patient over time
may be more qualified than a psychologist to assess the
medical aspects of the patient's personality (Nabarro, I
1967). !
In a somewhat similar situation of predicting |
adaptation and job success where there were no clear indi- ;
cations of what was expected, psychiatrists evaluated Peace j
i
Corps volunteers. The psychiatric diagnostic rating corre- i
lated the highest with job success at r =» .44. However,
psychiatric prediction ratings only correlated r = .18 with
success (Stein, 1966). The assessment in this case was not
confounded by personality changes due to medical illness.
A broad screening of emotional stability may be
necessary to weed out psychotics and severely disturbed
applicants. But it is unknown how personality and life
conditions affect cooperation in treatment (Enelow & Freed,
1967). The question remains if emotional stability can be
accurately measured and if it is in fact related to
dialysis adaptation.
136 !
Cooperation. Sanders and Dukeminier (1968) asked,
"What is cooperation?" They listed the following charac- |
jteristics considered to be minimal for hemodialysis
|treatment success: (a) the ability to learn to take care
i
!of the cannulas, to keep them clean and free from infec
tion, (b) the ability to adhere to a diet, (c) the ability
to tolerate complications, (d) the psychological ability to
tolerate the stress of "being saved" twice a week, (e) the
i
ability to live with uncertainty, (f) the ability to j
tolerate dependence, and (g) rehabilitation potential. j
!
Although cooperation is a basic requirement, there
is no way to directly measure patients for cooperative !
capacity or to predict their actual behavior in treatment.
Sanders and Dukeminier (1968) noted that psychiatrists and
social workers cannot easily predict which patients will
develop the qualities necessary for adjustment to life with
a machine. Meldrum et al. (1968) flatly stated that
jcooperation cannot be predicted.
i
: To complicate the role of cooperation in patient
adjustment, Norris (1968) indicated that the most coopera
tive patient, who adapts easily to the program, may be
least rehabilitatable. On the other hand, the independent,
generally uncooperative patient may be most rehabilitatable
'(Norris, 1968).
i
Since qualities of minimum cooperation may be
I
j mutually incompatible, how can cooperation be used as a_____
;selection predictor variable and how is cooperation objec-
itively measurable?
!
j Psychological and social values. Various centers
j stated that they do not exclude patients for socioeconomic
I
|reasons (Gonzalez et al., 1963; McLeod et al., 1966).
!Enelow and Freed (1967) stated that spurious psycho-social
values should not be used in selection since what is valued
morally and socially in some cultures may be negatively j
i
correlated with survival ability. Rebellion and an angry j
drive reflected in some antisocial traits may be associated!
with physiological resistance to stress (Enelow & Freed, |
1967). |
Psychiatric and psychological factors influencing
individual well-being have not been clearly elucidated
(Schupak et al., 1967). Therefore, should patients be
iselected on the basis of psychological comparisons?
i Sex. Katz and Procter (1969) found only 173 women
i
j
in the sample of 689 dialysis patients in 1967. However, a
study of survival rates of 302 patients, or roughly one-
third of the dialysis population, found no sex differences
in the survival rates of the patients (Lewis et al., 1969).
Lewis et al. (1969) concluded that the evidence does not
!
support the continued arbitrary selection criterion of
patient sex.
! 138 ;
Residency requirements. Residence proximity is not j
|pertinent to home dialysis. Various centers reported
patient success with home dialysis as far as thousands of
miles from the training center (Eschbach et al., 1967;
Rae et al., 1968; Shaldon, 1968b; Shapiro et al., 1968).
| The success of adaptation to a hemodialysis program
probably depends on many interrelated factors. To develop
an objective selection process would require examining many
specific bits of information on the patient and determining j
their relationship to criteria of adaptation success. j
The major selection criteria described above are in
strong need of validation or discard. However, some of j
these selection variables would have to be more objectively !
defined before they can be measured and verified. Before a
selection process can be developed and evaluated, objective
criteria variables are also required. Subjective staff
ratings of cooperation or adjustment as used in the Sand
let al. study (1966) are insufficient measures when used
i
I
|alone. In summary, optimum criteria for selection are
unresolved at this time (Sokol et al., 1967).
CHAPTER VII
METHOD
Introduction
This was a descriptive study in which a total of 96
|items covering a wide range of patient information were
examined in subsets for relationships to 78 objective
treatment criteria. This study used as predictor variables
the major selection criteria and treatment factors previ- !
i
i
ously reported as crucial to adaptation and rehabilitation, j
This study is viewed as the first of a number of (
studies in hemodialysis adaptation. Useful predictor j
variables disclosed in this project should be further j
examined and followed up in subsequent studies. Part of
the function of this study was to generate hypotheses for
;future research on selection procedures in home hemodialy-
|sis. The ultimate goal of this research would be to aid in
| improving ongoing patient care and in developing a more
objective selection process which would decrease the
current incidence of dietary, cannula, medical, and psycho
logical problems now found among patients.
139
1 140 :
I Subjects j
Subjects consisted of patients who are currently onj
home dialysis. Subjects were restricted to adult patients
jwho have been on home dialysis over 90 days. It was felt
that this time restriction would increase the accuracy of
|data obtainment as to what is happening on the home dialy
sis program once the patient has settled into the treatment
routine.
Thirty-seven patients living in the greater Los
Angeles area were used in this study. Initially, 40 j
|
patients were included, but three died during the course of|
data collection and were dropped from the study. This !
j
study then included approximately 80% of the available i
patients in the greater Los Angeles area.
The distribution of patients proportionally sampled
from the treatment hospitals was as follows: 3 from Harbor
jGeneral Hospital; 3 from Veterans Administration Wadsworth
j
IHospital; 6 from LAC-USC Medical Center; 12 from Pasadena
[Community Hospital; and 13 from Cedars-Sinai Medical Center.
I
Since the length of time on home dialysis varied
from three months to over three years, for statistical
purposes the subjects were grouped according to months on
home dialysis as follows: (a) 3 to 6 months, 7 patients,
(b) 6 to 12 months, 12 patients, (c) 13 to 24 months, 13
patients, and (d) 25 to 39 months, 5 patients.
Due to the limitation of sample size, patients from
different treatment facilities were pooled together.
: S
A separate analysis was done to determine if significant j
' treatment hospital differences existed.
Procedure
I Patient information used as predictor variables
consisted of survey data and psychological test scores.
Survey data were obtained from medical records, question
naires, and spouse interviews. Questionnaires were
i
administered to the patient, spouse, and staff of the j
treatment facility. j
Patient involvement. To obtain the psychological
test scores, each patient was tested in two sessions under i
two hours each. Both sessions occurred within one week of j
each other. Testing occurred in the home to eliminate a
potential fatigue variant since travel time to a facility
for testing would vary among patients.
i
| All testing occurred on the day the patient
|subjectively stated that he felt best to minimize varia
tions in psychological and biochemical balance states that
could influence test results. Although the maximal
clinical benefit from hemodialysis generally occurs within
the following 48 hours, maximal improvement has occurred 70
to 96 hours after dialysis (Smith & Vincent, 1966). There-
jfore patients vary cyclically as to when they feel best,
j Testing was postponed if the patient did not feel well on
the scheduled testing day. j
During Session I the WAIS and Mechanical Comprehen-j
;sion Test were administered, and the Patient Questionnaire
I(see Appendix A) and MMPI were left with the patient to be
completed before Session II. During Session II the
|Rosenzweig P-F Study and the Body Image Inventory were
iadministered. The spouse was given a Spouse Questionnaire
(see Appendix B) and interviewed. Materials previously
left with the patient were picked up.
i
Spouse involvement. The spouse completed a short |
i
!
questionnaire and was privately interviewed for about 30 j
j
minutes during the second home session. The purpose of i
i
this spouse contact was to assess the family support and
relationships with the patient, and to verify the patient's
statements regarding self-care, family support, and sexual
potency.
Staff ratings. Staff attitudes about aspects of
;the patient's personality were included as predictor
|variables in some of the statistical analyses. There is
I
some evidence that staff attitude towards the patient can
result in differential patient treatment or relate to
patient adjustment.
The Staff Questionnaire (see Appendix C) was more
I
jcomprehensive but replicated the questions used in the
|staff evaluation study by Sand et al. (1966). They obtained
143 |
ratings of cooperation, emotional adjustment, and recom- j
|
mendations of similar type future patients from the staff !
;which included nurses, nurses' aides, and physicians.
Patients were ranked into categories of "superior,"
|"adequate," or "poor" in terms of adjustment and coopera-
ition. Sand et al. (1966) found significant correlations
;for pretreatment predictions and ratings of cooperation and
adjustment taken two years later. The results of the Sand I
study may be biased in the use of subjective adaptation
criteria which could reflect the rater's personal reaction !
to the patient. Furthermore, a general consensus about a j
patient could have emerged from frequent staff meetings. j
j
This study attempted to shed further information on the j
value of staff ratings.
The Staff Questionnaire also included questions
pertaining to the staff member's opinion regarding sexual
!expectations of hemodialysis patients and whether this
|
|opinion was conveyed to the patient. An offhand observa-
i
tion disclosed differences in sexual functioning of
hemodialysis patients among the treatment centers. Staff
attitude of performance expectations may be a significant
factor for these wide differences.
Medical information. The treatment hospital filled
out a Medical Record (see Appendix D) on the patient's
medical data. Biochemical measures and medical
j 144 |
; complications were assessed as to occurrence within the
■ i
i preceding three months. It would have been better to have
| measures over a longer time span to accurately assess the
i
i incidence of complications; but due to time limitations
i
j this study involved a cross-sectional approach. The
| patient's physician filled out the material on incidence
of chronic medical complications.
Psychological Tests
A range of psychological tests were administered to
the patients. These tests and their rationale for inclu- j
|
sion in the psychological test are presented next.
Wechsler Adult Intelligence Scale (WAIS). The WAIS
was used as a general measure of intelligence and of
organic impairment.
Intelligence is a frequently stated requirement for
hemodialysis selection (Gombos et al., 1964; Hampers &
i
Merrill, 1966; Retan & Lewis, 1966; Sand et al., 1966).
However, other authors disclaim the role of intelligence in
! successful adaptation (Eschbach et al., 1967; Shaldon,
1968b) . One patient with an intelligence quotient of 85
continued to work and had fewer cannula problems than more
intelligent patients in the same unit (Schupak et al.,
1967). Patients with diminished intellectual capacities
have continued to do well on the program and became totally
rehabilitated and self-supporting (Schupak et al.^ 1967).
' - ' . ... - 145 |
This study attempted to obtain more information on
| i
!the relationship of intelligence test scores to adaptation I
i
I in chronic hemodialysis. The WAIS was chosen as the
| intelligence measure to conform to testing measures previ
ously obtained and reported in hemodialysis literature
j
|(Blatt & Tsushima, 1966; Sand et al., 1966; Schupak et al.,
1967; Short & Wilson, 1969).
WAIS testing on patients with terminal renal
failure prior to dialysis maintenance showed a consistent
pattern of intellectual deficit characteristic of persons j
with cortical dysfunction (Blatt & Tsushima, 1966). The
verbal score was significantly higher than the performance j
|
score which indicated a discrepancy in intellectual ability.
Digit symbol and block design were most impaired which
suggests a reduction in cortical efficiency.
Although continued hemodialysis lifts uremic
;symptoms, organicity has been reported in chronic hemo-
|dialysis patients (Barber et al., 1963; Short & Wilson,
j
11969). Several patients have been reported to develop
mental deterioration in the absence of localizing neurolog
ical signs and with good chemical control of uremia (Barber
et al., 1963). The changes in brain tissue were varied and
nonspecific; but the resulting reduction in comprehension
jand cooperation probably shortened their survival time
(Barber et al., 1963). Short and Wilson (1969) found a
jdiscrepancy of the performance level falling appreciably
r’ ~.. ”” ’.’ .... " 146
below the verbal level on the WAIS for long-term dialysis
patients which indicates organicity. Short and Wilson !
| believed that most hemodialysis patients in time develop a
J significant degree of "organic brain" dysfunction.
In this study the WAIS was used to verify the
| occurrence of suggested organicity in dialysis patients.
An attempt was made to determine if an organic pattern on
the WAIS is related to treatment factors, such as length of |
i
I
time between onset of symptoms and first dialysis, since j
some long-term patients show no organic effects. The j
relationship of an organic pattern on the WAIS to factors
of adaptation to a hemodialysis program was also examined, j
\
Test of Mechanical Comprehension (Form AA). This
test by George K. Bennett was used as a measure of mechan
ical aptitude. Shaldon (1968b) stated that for home hemo-
| dialysis success a reasonable mechanical aptitude was found
! to be more advantageous than intellectual attainment or
iprevious medical or paramedical experience. The inclusion
j
j of a mechanical aptitude test would yield some factual data
|
on the relationship of mechanical understanding to success
of home hemodialysis.
Minnesota Multiphasic Personality Inventory (MMPI).
I
The MMPI was included to measure personality characteris
tics and verify relationships of these characteristics to
i
[JLevel of adaptation. Other studies have indicated that
I 147 1
I ;
|denial as measured by the Hs, D, and Hy Scales and by
jFactor R, the index for appraisal of repression, become
I elevated as dialysis continues (Wright et al., 1966; Short
!& Wilson, 1969). Denial is a recognized adaptive defense
|mechanism for chronic hemodialysis patients to enable them
i !
j to cope with the stresses of their life situation.
Pretreatment hemodialysis patients have shown clin-
| ically significant scores on Paranoid, Pa, Schizophrenia,
!
Sc, or Psychopathic deviant, Pd, scales (Sand et al.,
1966). Patients who are seen as making poorer adjustment
'were more defensive on all scales and denied even normal
|
jamounts of adjustive difficulty and anxiety. Poorer
I i
iadjusting patients had the K scale, which measures defen-
i ;
jsiveness, as their most elevated scale (Sand et al., 1966).
Patients who later adapted better had lower Hypochondri-
iasis, Hy, and Hysteria, Hs, scales indicating fewer
isomatizing defenses than poorer adapting patients (Sand
let al., 1966). Patients who adapted better also had more ;
!elevated Depression, D, on the MMPI during predialysis
j I
candidacy (Sand et al., 1966).
i !
i An effort was made to examine the quantity of
|
!denial as related to good adaptation and rehabilitation.
jThe relationship of the Ego Strength scale, Dependency
i
I scale, and Factors A and R to successful adjustment was
i
also examined (Dahlstrom & Welsch, 1960). i
r ' ~ “ ... 148
Rosenzweig P-F Study. The P-F Study was adminis-
i
tered to assess direction of aggression to frustration. i
This test was designed to differentiate direction of
; aggression to frustration as either extrapunitive, intro-
| punitive, or impunitive. It also indicates whether the
I
i response given to a frustrating situation is ego-defensive,
! dominated by the obstacle, or shows a need to solve the
frustrating problem (Rosenzweig, 1944; Rosenzweig, 1945). j
i
The life of a hemodialysis patient is characteris- |
|
tically stressful and frustrating. His stance towards
I
frustration may have some adaptive meaningfulness.
Patients with a high intropunitive score may direct their j
aggression self-destructively and have more diet adherence
i
and cannula problems. Patients with a high extrapunitive j
score may direct their aggression to their families or
staff and be considered difficult to get along with.
;Patients high on need-persistence may be more adaptive
!while patients high on obstacle-dominance may take a more
passive-dependent stance and be slower to rehabilitate.
Body Image Test. The Body Image test by Schwab and
Harmeling (1968) was used as a measure of body satisfac
tion. A loss or disturbance of body image has been
reported among patients on chronic dialysis (Abram, 1969b;
Schreiner, 1969; Wright et al., 1966). Schwab and
|Harmeling (1968) found that extension of negative feelings
I toward the body as a whole, with scores reflecting_________
i 149 ;
dissatisfaction with many bodily parts and functions,
; i
correlated with indices of emotional distress.
t
j
This study examined the relationship of body image
to criteria of adjustment and rehabilitation. In partic
ular, it examined whether patients who are unemployed and
[unable to function sexually have lower body image scores.
j
j These tests were chosen because they appeared
related to published selection considerations and to
previous testing literature. They also appeared to be able
to maximize the information obtainable in the limited
!
available testing time. The projectives such as the I
i
Rorschach, Thematic Apperception Test, and the Draw-A- |
Person would yield the most dynamic information on the
patient regarding his defenses, ego strength, and body
image. However, they were excluded in this study because
of the limitation of using only objective predictor
[variables.
Predictor Variables
I
A total of 96 items of information were used in
various subset analyses. A list of these items is presented
below. The letter in parenthesis indicates their source, as
follows: (P) = patient questionnaire; (S) = spouse ques
tionnaire; (M) = medical records; (H) = staff ratings; and
(T) = psychological test scores.
150
General patient information
1. (P) Age.
2. (P) Over 45 years of age.
3. (P) Sex.
4. (P) Years of schooling.
5. (P) Years of marriage.
6. (P) Number of children living at home.
7. (P) Current combined annual income.
8. (P) Proportion of patient's annual dialysis costs
to annual income.
9. (P) Worry over finances.
Prehome hemodialysis information
10. (M) Acquired vs. congenital basis of renal disease.
11. (P) Months between diagnosed kidney disease and
symptom onset.
12. (P) Months between symptom onset and first
peritoneal dialysis or hemodialysis.
13. (M) Serum creatinine before first dialysis.
14. (P) Weeks between first peritoneal dialysis and
first hemodialysis.
15. (P) Hours per week of hospital hemodialysis.
16. (P) Weeks of hospital hemodialysis before beginning
home training.
17. (P) Number of weeks of home training.
18. (P) Total training hours.
19.
20.
21.
2 2 .
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
Home hemodialysis information
(P) Number of months on home hemodialysis.
(P) On home hemodialysis over one year.
(P) Parallel-plate vs. coil dialyzer.
(P) Use of blood pump during dialysis.
(P) Location of shunt.
(P) Shunt on preferred arm.
(P) Distance from home to treatment center.
(P) Hours per week of home dialysis.
(P) Number of dialyses per week.
(P) Hours per week in maintenance of equipment.
(P) Primary responsibility for dialysis operation.
(P) Day vs. night dialysis schedule.
(P) Sleep during dialysis.
(P) Patient's self-confidence about handling the
dialysis.
(P) Patient's confidence about the helper.
(S) Helper's self-confidence about handling the
dialysis.
(P) Range of weight loss during dialysis.
(P) Average weight loss during dialysis.
Current medical information
(P) Expectation of transplant.
(P) Current urine quantity in a 24-hour period.
(P) Months under 800 cc. urine output per 24-hour
151
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
152 !
period.
(M) Both kidneys removed.
(P) Greater bleeding problems not attributable to
heparin or coumadin.
(P) Total transient symptoms generally experienced
following dialysis.
(M) Total shunt problems.
(M) Total measures indicating dietary nonadherence
i
and dialysis inadequacy. j
(M) Current neuropathy compared to neuropathy when
began dialysis. j
(M) Hypotension during dialysis.
(M) Hypertension during dialysis.
(M) Diagnosed myocardial failure, congestive heart
failure, or pulmonary edema.
(M) Total diagnosed chronic medical complications.
Treatment differences
(P) Cedars-Sinai Medical Center vs. others.
(P) Veterans Administration Hospital vs. others.
(P) LAC-USC Medical Center vs. others.
(P) Harbor General Hospital vs. others.
(P) Pasadena Community Hospital vs. others.
(P) MAKS 900 machine vs. others.
(P) MAKS 990 machine vs. others.
(P) Drake Willock machine vs. others.
(P) Milton Roy machine vs♦ others . __________________
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
153 !
Emotional adjustment
(P) Differential of marital happiness pre- and
postdialysis.
(P) Patient rating of emotional support from the
family.
(H) Staff rating of emotional support from the
family.
(H) Staff rating of patient's cooperation with
medical requirements and in working for his j
t
own successful treatment. j
(H) Staff rating of patient's emotional adjustment
to living as an artificial kidney patient.
(H) Staff rating of patient's motivation to be a j
I
productive member of the community. j
(H) Patient more dependent and reluctant to do
things for himself than others.
(H) Patient more independent and resentful or
resistant to reasonable assistance than others.
Sexual functioning information
(S) Sexual attractiveness of the patient to the
spouse.
(H) Impotency discussed with the patient by the
staff.
(H) Patient told by the staff that impotency or
decreased sexual activity is a common occur
rence with dialysis patients. _____
154 I
Psychological test scores i
70. (T) WAIS Full Scale score.
71. (T) WAIS Verbal Scale score.
72. (T) WAIS Performance Scale score.
73. (T) Patient Mechanical Comprehension score.
74. (T) Combined operator Mechanical Comprehension
averaged score.
75. (T) Body Image score.
76. (T) P-F Study Extrapunitive vs. Intropunitive
score.
77. (T) P-F Study E-ED predominant response combination
vs. other.
78. (T) P-F Study Group Conformity Rating.
79. (T) MMPI L scale.
80. (T) MMPI F scale.
81. (T) MMPI K scale.
82. (T) MMPI Hs scale.
83. (T) MMPI D scale.
84. (T) MMPI Hy scale.
85. (T) MMPI Pd scale.
86. (T) MMPI Mf scale.
87. (T) MMPI Pa scale.
88. (T) MMPI Pt scale.
89. (T) MMPI Sc scale.
90. (T) MMPI Ma scale.
91. (T) MMPI Factor R scale.
92. (T) MMPI Factor A scale.
93. (T) MMPI Dependency scale.
94. (T) MMPI Ego Strength scale.
95. (T) MMPI Neurotic index.
96. (T) MMPI Psychotic index.
!
jCriteria Variables
Criteria variables were selected on the rationale
that adjustment in home dialysis is objectively measurable
in two areas: (a) minimum incidence of medical complica- I
|
tions, and (b) rehabilitation, or resumption, as much as i
i
realistically possible, of the previous life style. j
i
Rehabilitation criteria included the following three areas: i
. j
(a) job, (b) sexual potency, and (c) activity level.
A distinction may be necessary between treatment program
adaptation and rehabilitation since some rehabilitated
jpatients are treatment rebels.
A total of 78 criteria variables were used in
|
ivarious subset analyses. Since this is a cross-sectional
study, the occurrence or frequency within the three months
preceding the date of psychological testing is the basis of
measurement. A list of these items is presented below.
The letter in parenthesis indicates their source as
follows: (P) = patient questionnaire; (M) = medical
|records; and (T) = psychological test score.
i
|
155 !
156
Shunt information
1. (P ') Number of times patient declotted shunt.
2. (M) Number of times shunt declotted at hospital.
3. (M) Number of surgical repairs of arterial line.
4. (M) Number of surgical repairs of venous line.
5. (M) Number of shunt infections.
6. (M and P) Total number of shunt problems.
Dietary adherence
7. (M) Frequent weight loss during dialysis over
1 kilogram.
8. (P) Range of weight loss during dialysis.
9. (P) Average weight loss during dialysis.
10. (M) Predialysis serum potassium over 6.5.
11. (M) Serum albumin below 3.5 exclusive of illness
or infection.
Adequacy of dialysis
12. (M) BUN over 90.
13. (M) Serum creatinine over 16.0.
14. (M) Predialysis phosphate over 10.0.
15. (M) Predialysis uric acid over 9.0,.
16. (M) Total excess biochemical measures.
Transient symptoms during dialysis
17. (P) Nausea.
18. (P) Vomiting.
157
19.
(P)
Leg muscle cramps.
20.
(P)
Headaches.
21.
0?)
Dizziness.
22.
(P)
Sleepiness.
23.
(P)
Restlessness.
24.
(P)
Irritability.
25.
(P)
Irregular heartbeat.
26.
(P)
Total transient symptoms experienced.
Transient svmotoms following; dialvsis
27.
(P)
Listlessness.
28.
(P)
Irritability.
29.
(P)
Nervousness.
30.
(P)
Depression.
31.
(P)
Headaches.
32.
(P)
Leg muscle cramps.
33.
(P)
Sleepiness.
34.
(P)
Nausea.
35.
(P)
Vomiting.
36.
(P)
Restlessness.
37.
(P)
Low blood pressure.
38.
(P)
Dizziness.
39.
(P)
Total transient symptoms experienced.
Chronic medical complications
40. (P) Trouble sleeping.
41. (P) Regular medication for nerves or sleep.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
158 |
(P) Greater bleeding problems not attributable to
heparin or coumadin.
(P) Occurrence of tingling or numbness in the hands
or feet.
(P) Occurrence of "burning foot" syndrome.
(P) Occurrence of uncontrollable restlessness,
agitation, or twitching of legs.
(P) Occurrence of muscle weakness or paralysis in
feet or legs.
(P) Occurrence of intense "itching" skin.
(M) Number of days of hospitalization.
(M) Hypertension during dialysis.
(M) Hypertension requiring medication.
(M) Hypotension during dialysis.
(M) Diagnosed renal osteodystrophy.
(M) Current neuropathy compared to neuropathy when
entered dialysis.
(M) Diagnosed sensory peripheral neuropathy.
(M) Diagnosed motor peripheral neuropathy.
(M) Diagnosed pruritis.
(M) Diagnosed impotence.
(M) Diagnosed gastrointestinal bleeding.
(M) Diagnosed sepsis.
(M) Diagnosed myocardial failure, congestive heart
failure, or pulmonary edema.
(M) Total numberof diagnosed chronic medical ____
complications.
62. (T) WAIS organic brain damage pattern.
63. (T) WAIS impairment of immediate memory.
Work rehabilitation
64. (P) Current hours worked per week.
65. (P) Decrease in work hours following dialysis.
66. (P) Change in occupation following dialysis.
67. (P) Less activity following dialysis.
Sexual functioning rehabilitation
68. (P) Current level of sexual performance compared
to predialysis level.
69. (P) Satisfaction with current sexual performance.
70. (P) Occurrence of impotence.
71. (P) Months of impotence.
Patient psychological well-being
72. (P) Current marital happiness compared to pre
dialysis marital happiness.
73. (P) Current happiness compared to people in general.
74. (P) Current happiness compared to other dialysis
patients.
75. (T) MMPI Depression scale.
76. (T) MMPI Factor R (denial, rationalization) scale.
77. (T) MMPI Factor A (personal distress, anxiety)
scale.
78. (T) MMPI Ego Strength scale.
159
, 160
Pretest of Procedures
A small pilot study using eight hemodialysis
patients who regularly dialyzed in the Wadsworth Hospital
j was undertaken to check out the proposed method of data
collection prior to studying the home patients. These data
i
! were not analyzed since they were only by-products to the
| major purpose of examining the utility and feasibility of
proposed patient, spouse, and staff participation.
Medical records at each hospital were examined to j
I
see if adequate data were available on all the optimum
criteria variables listed. Following this ’’trial run” of j
data gathering, minor simplifications and modifications of j
the procedure occurred. j
j
j
Statistical Design and Analysis
Due to realistic cost and time factors this study
:employed a cross-sectional approach in which criteria
I
jmeasures involved frequency of occurrence within the three
■months preceding the data collection. However, efforts
I were made to equate the patients. First, the patient was
examined on a day when he was feeling his best. Second, a
particular patient's adaptation was evaluated through
comparison of his criteria measures with those of other
patients with the same amount of total time on home
|dialysis. It was expected that length of time on dialysis
i
would greatly affect criteria measures, especially those
161 j
!involving chronic medical complications. Therefore, j
patients were divided into groups of total time on home
:dialysis.
| Data analysis consisted of data screening, descrip-
tive analyses, intercorrelation matrices, and multiple
|regression analyses. The Western Research Support Center
jat the Sepulveda Veterans Administration conducted all the
data analyses.
To insure that the mass of data could be "boiled
down" to yield statistically meaningful statements, statis-j
I
tical analyses occurred in the following two stages:
i
Stage I. For statistical handling, all variables !
were numerically scalable. An initial descriptive pass j
i
yielded: (a) cumulative frequency, (b) cumulative percent-|
age, (c) mean, (d) standard deviation, SD, (e) standard
error of the mean, SEm, (£) skewness and t_ test of skewness,
and (g) kurtosis and t. test of kurtosis of each variable.
Correlation matrices were also done for each questionnaire.
At this point some variables which were redundant or useful
only for descriptive purposes were dropped from further
analyses.
Stage II. The remaining variables were further
reduced by combining criteria measures into subsets such
as cannula problems, chronic medical problems, and others
for separate multiple regression analyses. The predictor
162 j
variables significantly related to each criterion variable |
within a regression subset were identified. These further
ianalyses reduced the set of predictor variables. Predictor
! variables which correlated with the criteria because they
jare a function of other significant predictor variables
j
[were identified and eliminated. The multiple regression
analyses yielded over 3,000 t. tests for each criterion
variable among all the subset analyses. F ratios on each
i
I
criterion variable were also obtained. !
I
A priori hypotheses previously proposed were j
verified from the individual _t tests and from the intercor-I
j
relation matrices for the multiple regressions. This is anj
!
alternative method to a factor analysis for obtaining the j
significance of group differences.
Function of This Study
One value of this study was the obtainment of
|objective information on the absolute incidence of various
life characteristics of a large sample of home hemodialysis
patients. This information could indirectly help in
understanding and decreasing patients' problems. This
information has been previously available only from a small
!
_ sample of patients or through subjective speculation.
This wide systematic overview study was a necessary
first step in objectively uncovering interrelated factors
i
[of adaptation for future study. Later studies can confirm
r ' . . . . . . . * " 163 ’
|the results of this project by making predictions, based on
|the findings of this research, on patient success from data
gathered on accepted candidates before their admission to
dialysis treatment. These patients would then be followed
over time with criteria measures periodically taken.
Future studies could also be directed to improving patient
|adaptation after onset of home dialysis.
CHAPTER VIII
DESCRIPTIVE RESULTS
Introduction
The following information was obtained from the
frequency distributions on the data obtained on the 37
subjects used in this study. This chapter supplies a
comprehensive range of factual information on the sample
|
population. It attempts to answer the first question j
raised in this paper, namely, what is occurring on the home
dialysis program for patients in the Los Angeles area.
Characteristics of the
Patient Population
Patients in this study were predominantly: (a)
jmale, 62%, (b) between 35-54 years of age, 60%, (c) high
school graduates, 70%, (d) of average intelligence, 54%,
(e) married, 92%, and (f) without children under 16 years
of age, 62%.
Sex. The ratio of males to females was approxi
mately the same as that found by Katz and Procter (1969) in
their 1967 nationwide population survey of dialysis
patients.
164
Age. The patients ranged from 22 to 66 years of j
[age with a mean of 43.7 years (SD = 11.16; SEm =1.83).
jA majority (54%) were over 45 years of age. In contrast
|
|Katz and Procter found only 34% of the 1967 dialysis
'population over 45 years of age.
!
Education. Years of completed schooling ranged
from 5 to 18 with a mean of 12.5 years (SD = 2.82; SEm = j
0.46). Fewer patients in this study (35%) had attended
college than the 1967 survey findings. In 1967, 45%, of the
t
total dialysis population had completed one or more years I
i
of college. j
For patients in this study, age was negatively j
correlated with years of school (r = -.56). Since more j
older patients are found in this sample, this could account
for the smaller proportion of college attendance than in
the 1967 survey.
I
| Intelligence. Level of functioning intelligence
ranged from 70 to 131 with a mean of 105.4 (SD = 13.34;
SEm = 2.19) which falls in the average range. This is only
slightly higher than the general population mean of 100.
| In the general population, 25% are above average in
intelligence compared to the 35% above average in this
jstudy. However, the proportion of average intelligence is
i
i
[similar in both the general population (50%) and this study
sample (54%). No mental defectives were found among these j
lpatients.
The breakdown of categories among these patients
included: Borderline (3%); Dull normal (8%); Average (54%);
Bright normal (22%); Superior (107o); and Very superior
(3%) .
I
Marital status. Only 3 of the 37 subjects, or 8%,
were not married.
j
Number of dependents. Of the patients in this j
sample, 65% had children while only 38% had children under j
16 years of age. Of the patients with younger children
only 8% of this group had more than two children under 16 |
i
years of age. However, 54% of the patients had children
living at home.
;Conclusions about Selection Determinants
| The Los Angeles treatment hospitals seem to have a
I liberal selection policy and do not appear to be biased in
I
selecting patients on the bases of younger age, education,
|intelligence, or number of dependents. Over half of the
patients in this study were 45 years of age or older.
Average level of intelligence in the Bright normal range
(M = 115) has been reported for home dialysis patients in
|the literature (Sand et al., 1966). Although hospitals in
this study did not appear to choose bright candidates for
home dialysis, there appears to be a tendency to exclude j
; i
i
i below average patients in favor of average patients. Only
|11% of the patients in this study were below average in
|
| intelligence compared to 25%, in the general population.
j
Less than 10% of the patients in this study were
single or non-Caucasian. Also, males outnumbered females
|over 2:1. Sex, race, and marital status biases may be
operating in the selection of home patients in this area.
However, there is no way at this time to determine if, in j
i
fact, these selection biases exist since medical and
financial determinants may account for this skewed distri- i
bution. In general there appear to be fewer selection j
|
biases in this sample than reported in the literature. j
|
Predialvsis Characteristics
Most patients had chronic renal failure rather than
acute renal failure. Time between illness and symptom
i
|onset varied between 0 and 360 months with a mean of 43.7
j
jmonths (SD =■ 87.56; SEm = 14.39). Elapsed time between the
|occurrence of symptoms and first dialysis (either peritoneal
or hemodialysis) ranged from 0 to 99 months with a mean of
38.2 months (SD = 39.48; SEm = 6.49)
The majority of the patients (65%) were first given
I peritoneal dialyses. Half of these patients, or 12,
received less than three peritoneal dialyses before begin
ning hospital hemodialysis. The other 50% received from
| ‘ ' 168 |
i 4 to 28 peritoneal dialyses. The number of peritoneal I
|dialyses before beginning hemodialysis ranged from 0 to 28
Iwith a mean of 3.1 (SD =» 4.95; SEm = 0.81).
The time interval between the first peritoneal
dialysis and first hemodialysis ranged from one to 52 weeks
with a mean of 8.8 (SD =» 12.10; SEm = 1.99).
Hospital Hemodialysis and Training
i
One patient bypassed hospital hemodialysis and
initially started home training and home dialysis simul
taneously. The rest received hospital hemodialysis and j
I
some training in the hospital before dialyzing at home. |
Number of hours per week of hospital dialysis |
ranged from 12 to 30 hours with a mean of 21.4 hours (SD =
5.63; SEm = 0.93). The most frequently used schedule of 24
hours per week occurred for 35%, or 13, of the patients.
More than 24 hours of hospital dialysis was received by 22%
|of the patients while 43% received less than 24 hours per
j
iweek.
The majority of the patients (65%) started home
training during the first week of hospital dialysis. Other
schedules of onset of home training following hospital
dialysis included: 1 to 4 weeks (19%); 8 weeks (8%); and
14 to 32 weeks (8%). Weeks of hospital dialysis before
beginning home training ranged from 0 to 32 weeks with a
mean of 3.1 weeks (SD = 6.88; SEm = 1.13). Patients
i -... 1 69 |
dialyzed longer than four weeks before beginning home
[training may have been shifted from an inpatient program. |
I The number of weeks of home training ranged from
i
2 to 18 with a mean of 7.6 weeks (SD =* 3.33; SEm = 0.56).
The total number of training hours ranged from 51 to 390
hours with a mean of 171.6 hours (SD = 83.01; SEm = 13.65).
j _
The distance of the patient's home to the treatment
center ranged from one to 65 miles with a mean of 23.6
miles (SD * 16.27; SEm =2.67). !
i
Management Problems for the Staff
Staff members including nurses, social workers, and j
i
physicians who had close contact with the home patients
rated the patients on cooperation, motivation to be a
productive member of the community, emotional adjustment,
and general behavior compared to the other patients.
| The staff members' personal contact with the
|patient ranged from 3 to 31 months with a mean of 14.2
!
jmonths (SD = 6.30; SEm = 1.04). The average number of
i
times per month that the patient was seen by the staff
member ranged from 1 to 3 times with a mean of 2.1 times
(SD - 0.72; SEm = 0.12).
In rating the patient's general behavior compared
to other home dialysis patients, the following problems
emerged in the sample: (a) more anxious or worried, 38%;
(b) more upset when things go wrong, 35%; (c) generally
170 :
more depressed, 30%; (d) more dependent and reluctant to do
ithings for himself, 27%; (e) more frequently or easily
jirritated, 24%; (f) demands more attention or favored
handling, 19%; and (g) more independent and resentful or
resistant to reasonable assistance, 11%.
i It appears that the greatest management problems
i
with this study sample involves dealing with patients'
feelings of anxiety or depression and in helping the
patients handle technical problems without becoming emotion-!
ally upset. Overdependency is a frequent problem while j
overindependency is seldom encountered in these patients. I
Management problems are global for some patients. |
Patients who were rated as more upset when things go wrong j
|
had strong positive correlations to also: (a) wanting more ;
attention, r = .65, (b) being more depressed, r = .64, (c)
being more worried, r = .59, and (d) being more irritable,
r = .51 than the average patient. Patients more depressed
also tended to want more attention, r = .59, and to be more
jdependent, r =» .54. Patients wanting more attention also
j
had strong positive correlations with being more irritable,
ir = .69, and more dependent, r = .64.
Good emotional adjustment to living as an artificial
kidney patient seems to be a crucial determinant to adapta
tion and absence of management problems. Patients rated
high by the staff in emotional adjustment had strong
I
positive correlations to staff ratings of: (a) appearing __
: 171 |
happy and leading a normal life, r = .93, (b) showing j
; motivation to be a productive member of the community,
i i
j
jr = .66, and (c) receiving emotional support from his
family, r => .59. Patients ranked high in emotional adjust
ment had negative correlations with management problems
j
|such as: (a) depression, r = ~.59, (b) worry, r = -.57,
and (c) irritability, r = -.55. Patients rated high in
happiness and leading a normal life were also rated high,
r ® .76, in motivation to be a productive member of the
community.
I
Dialysis-Related Characteristics )
Patients in this study predominantly: (a) used a
parallel-plate dialyzer, 78%; (b) did not use a blood pump,
70%; (c) shared the dialysis operation with their spouse or
child, 62%; and (d) dialyzed on a night schedule, 65%.
| Equipment. Four out of five patients used a
parallel-plate dialyzer. Generally a blood pump is not
|necessary with a parallel-plate dialyzer, but three of the
patients with a parallel-plate dialyzer used a blood pump.
All patients with a coil dialyzer regularly used a blood
pump.
The distribution of machines was as follows: (a)
Maks 900, 22%; (b) Maks 990, 16%; (c) Drake Willock, 41%;
(d) Milton Roy, 16%; and (e) Travenol, 5%.
! ' ' ~ 172
Self-responsibility. Previous studies have j
istressed the need for the patient to assume responsibility j
ifor operation of the dialysis treatment (Eschbach et al.,
i 1967; Tsaltas, 1967). However, only 19% of the patients in
i
jthis study operated their equipment. Another 19% had no
active participation in the procedure and relied on a
trained nurse or family member to operate the equipment.
The majority of the patients, or 62%, then shared the j
j
operation with a family member. !
Self-operation of dialysis was negatively corre- j
i
I
lated to age, r = -.51, and positively correlated to
responsibility for cleaning equipment, r = .57. Younger j
patients were more inclined to take total charge of the j
dialysis operation and of cleaning the equipment.
Day vs. night schedule. Only 22% of the patients
idialyzed primarily during the day while 13% had a mixed day
|and night schedule. The majority of the patients, or 65%,
jdialyzed primarily during the night.
A majority of the spouses, or 577OJ complained about
a lack of adequate sleep and of feeling more tired since
dialysis. Their fatigue may be related to their assistance
with the dialysis operation which generally occurs at night.
Length of time on home dialysis. The patients were
almost evenly divided between being on home dialysis up to
12 months (51%) and over 12 months (49%).
! 173
The breakdown of months on home dialysis is as
follows: (a) 3 to 6 months, 19%, (b) 8 to 12 months, 32%,
j (c) 16 to 24 months, 35%, and (d) 25 to 39 months, 14%.
The number of months on home dialysis ranged from
3 to 39 with a mean of 15.6 months (SD = 9.87; SEm - 1.62).
!
Number of hours per week of dialysis. The number
of hours per week of home dialysis ranged from 10 to 32
with a mean of 22.8 hours (SD =* 5.11; SEm = 0.84). Number j
of hours per week of home dialysis correlated positively
with number of hours per week of hospital dialysis, r = 64,
and with total training hours, r = .56. Current dialysis
hours might reflect, in part, schedules developed during I
i
training.
Number of dialyses per week. The number of dialy-
|ses per week ranged from 2 to 5 with a mean of 3.25 (SD =
10.74; SEm “ 0.12). The distribution of the dialysis
i
|schedule per week included: (a) 2 times per week, 13%,
|(b) 3 times per week, 46%, (c) 3.5 times per week, 13%,
(d) 4 times per week, 22%, and (e) 5 times per week, 6%.
I
Maintenance of equipment. The number of hours
spent each week in cleaning and repairing the equipment
ranged from 3 to 24 hours with a mean of 8.7 hours (SD =*
4.34; SEm = 0.71).
There is a positive correlation between type of
174
dialyzer and maintenance time, r => .82. Patients with a
iparallel-plate dialyzer expectedly spent more hours per
week in maintenance.
Only 27% of the patients took full responsibility
for cleaning their equipment. Patients shared the task
with a family member in 41% of the cases. A family member
did the task with little or no help from the patient in 32%
|of the cases.
Confidence about operating the equipment. Regard
ing self-confidence about the ability to operate the
dialysis process and handle any emergency: (a) 64% of the
patients had strong self-confidence, (b) 22% had weak self-
confidence; and (c) 14%, had no self-confidence.
The patients had slightly more confidence about
their helper's ability. Regarding the ability of the
jhelper: (a) 67% of the patients had strong confidence, (b)
j19% had weak confidence, and (c) 14% had no confidence.
Helpers tended to be less self-confident of their
ability than the patient. Of the helpers: (a) 60% had
strong self-confidence, (b) 24%, had weak self-confidence,
and (c) 16% had no self-confidence.
Financial Aspects of Dialysis
175 !
Combined annual income. Patients were normally j
|distributed on combined annual income as follows: (a) less
|than $3,000, 8%, (b) $3,001 to $5,000, 16%, (c) $5,001 to
j$10,000, 22%, (d) $10,001 to $15,000, 30%, (e) $15,001 to
|$20,000, 13%, and (f) over $20,001, 11%.
Cost of dialysis. Many of the patients in this
study were receiving financial help from insurances or |
grants to cover the cost of dialysis. The cost of dialysis i
i
was less than 20% of their combined annual income for a j
majority, or 54%, of the patients. Dialysis costs were
between 21 and 40% of their combined annual income for 32% |
i
of the patients. Dialysis cost more than half of the i
combined annual income for only 14% of the patients.
Worry over finances. Patients worried more than
ithe spouses over finances. In this study 16% of the
jpatients and 11% of the spouses worried about finances very
much or all the time. On the other hand, 19% of the
patients and 307o of the spouses never worried over finances.
For the patients, financial worries correlated
negatively with combined income, r = -.40. There was no
appreciable correlation for the spouses between combined
jannual income and financial worries, r = .07. Therefore,
[poorer patients tended to worry more while wealthy spouses
worried as much as poorer spouses.
i “ _ .. ~ “ ' _ 176
jTransient Symptoms during Dialysis
I During dialysis the majority of the patients gener
ally experienced: (a) headaches, 68%, (b) leg muscle
|cramps, 65%, (c) sleepiness, 57%, and/or (d) restlessness,
|54%. Less than 20% of the patients regularly experienced:
i
|nausea, irregular heartbeat, or vomiting during dialysis.
A breakdown of the percentage of occurrence of
■transient symptoms generally experienced during dialysis
|
included the following:
Sym ptom
P e r C e n t
M ild
P e r C en t
S e v e r e
T o t a l
P e r C e n t
H e a d a c h e 60 8 68
L eg m u s c le cra m p s 54 11 65
S l e e p i n e s s 49 8
57
R e s t l e s s n e s s 41 13 54
I r r i t a b i l i t y 27 11 38
D i z z i n e s s 24 3 27
N a u s e a 14 5 19
I r r e g u l a r h e a r t b e a t 16 0 16
V o m itin g 11 3 14
Dizziness, sleepiness, irritability, and irregular heart
beat appeared to be interrelated symptoms during dialysis.
Dizziness positively correlated with: (a) sleepiness, r = !
.73, (b) irregular heartbeat, r =» .56, and (c) irritability,)
r = .53, Irregular heartbeat correlated positively with:
i
(a) sleepiness, r = .66, (b) irritability, r = .53, and (c) j
nausea, r = .53.____________________________________________
; 177 j
I Transient Symptoms on the j
;Day Following Dialysis !
Sleepiness was the only transient symptom experi-
i
enced by a majority of the patients, or 54%, on the day
following dialysis. However, over one-third of the patients:
generally experienced: (a) listlessness, 46%, (b) depres-
|sion, 43%, (c) leg muscle cramps, 40%, or (d) nervousness,
38%.
A breakdown of the percentage of occurrence of
transient symptoms generally experienced on the day follow
ing dialysis included the following:
Per Cent Per Cent Total
Symptom Mild Severe Per Cent
Sleepiness 49 5 54
Listlessness 41 5 46
Depression 40 3 43
Leg muscle cramps 35 5 40
Nervousness 35 3 38
Headaches 24 8 32
Irritability 30 0 30
Low blood pressure 30 0 30
Dizziness 27 3 30
Restlessness 27 3 30
Nausea 19 3 22
Vomiting 8 3 11
Generally speaking, transient symptoms occurred
with less frequency on the day following dialysis than
jduring dialysis. The "dizzy-sleepy-irritable-irregular
|
|heartbeat" syndrome during dialysis appeared to contribute
I
]
I to day after effects.
i
i Irritability during dialysis was positively corre
lated to the following day after symptoms: (a) irritabil
ity, r = .68, (b) headache, r = .67, and (c) nausea, r =
.50. Irregular heartbeat during dialysis correlated
positively with listlessness following dialysis, r = .60, j
and nausea following dialysis, r = .50. Nausea during j
dialysis correlated positively with listlessness following j
dialysis, r = .60. Dizziness during dialysis correlated j
positively with nausea following dialysis, r = .66, and
listlessness following dialysis, r = .56.
Symptoms of listlessness, irritability, and nausea
I on the day following dialysis appeared to be interrelated.
[Following dialysis, listlessness was correlated positively
1 to nausea, r = .77, and to irritability, r = .55. Leg
muscle cramps and sleepiness also appeared to be two inter
related day after symptoms, r = .77.
Depression on the day following dialysis correlated
the highest with nausea during dialysis, r = .58, and with
headaches during dialysis, r = .58. Patients who vomit
|during dialysis were likely to vomit on the day following
I dialysis, r = .70.
, 179
J
■ »
Average weight loss' during dialysis did not appear I
to be strongly related to symptoms during dialysis. How- !
lever, average weight loss during dialysis was positively
correlated to the day after effects of sleepiness, r =■ .78,
and to leg muscle cramps, r = .70. Patients who lose the
'highest absolute weight loss during dialysis tended to
I experience the following day after dialysis symptoms:
(a) leg muscle cramps, r = .80, (b) sleepiness, r = .58, j
or (c) nervousness, r = > .50. j
I
It then appears that proper sodium and water intake!
has no effect on lessening of symptoms during dialysis. I
But proper sodium and water intake can lessen the occur- j
I
rence of leg muscle cramps, sleepiness, and nervousness on |
the day following dialysis.
: i
; I
Current Medical Information
The basis of the renal failure was acquired in 70%
I of the patients and congenital in 30%.
i
The majority of the patients, or 81%, had both
kidneys intact. Eight per cent had one kidney removed and
11% had both kidneys removed.
The majority of the patients, or 51%, voided
between 800 cc. and 1 oz. of urine in a 24-hour period.
Less than 1 oz. of urine in a 24-hour period was voided by
33%. Over 800 cc. of urine in a 24-hour period was voided
by 16%, of the patients. The number of months under 800 cc.
i 180 |
! urine per 24 hours ranged from 0 to 48 months with a mean j
I of 12.9 months (SD = 10.64; SEm =1.75). !
I
j Months under 800 cc. urine was positively corre-
i
lated with months of home dialysis, r = .62. This might
indicate that residual kidney function declines over time
with dialysis management.
The majority of the patients, or 65%, were suitable
I
for transplant. But only 38% of the patients had an j
I
i
expectation of transplant and viewed home dialysis as a ;
i
temporary procedure until a transplant kidney was avail- !
able.
A significant minority of the patients, or 46%,, j
currently had greater bleeding and coagulation problems
which were not attributable to heparin or coumadin.
The total number of days of hospitalization in the
past three months preceding this study ranged from 0 to 30
idays with a mean of 3.6 days (SD = 7.60; SEm = 1.25).
At the time of beginning hospital dialysis, the
I
I predialysis serum creatinine ranged from 4.7 to 23.0 with
|a mean of 14.2 (SD = 4.21; SEm = 0.69).
j
Current Neuropathy Information
Of the patients in this study, 35% never had
diagnosed neuropathy. For the remaining 65% of the
patients, neuropathy improvement had occurred for 41%
while 24% of the cases remained unimproved.
181
A majority, or 70%, stated that they had experi
enced tingling or numbness in the hands or feet at one
itime during dialysis. Within the three months preceding
I
|this study, tingling or numbness in the hands or feet had
J
jbeen: (a) absent for 46%, (b) less severe for 32%, (c) the
I same for 8%, or (d) more severe for 14% of the patients.
Only 27% of the patients ever experienced burning
feet during dialysis. Within the three months preceding
this study, burning feet had been: (a) absent for 81%,
(b) less severe for 11%, (c) the same for 5%, and (d) more
severe for 3% of the patients than previously during home
dialysis.
A majority of the patients, or 57%, have had muscle
weakness. Within the preceding three months, muscle
weakness had been: (a) absent for 54%, (b) less severe for
.22%, (c) the same for 13%, and (d) more severe for 11% of
ithe patients than previously during home dialysis.
I
i
Chronic Medical Complications
The patient's physician identified the occurrence,
in the three months preceding this study, of the following
major medical complications:
182
Per Gent
Symptom Occurrence
Anemia 100
Hypertension during dialysis 38
Sensory peripheral neuropathy 32
Hypotension during dialysis 27
Impotence 24
Pruritis 22
Motor peripheral neuropathy 19
Renal osteodystrophy 16
Myocardial failure, congestive heart
failure, or pulmonary edema 16
Hypertension requiring medication 14
Gastrointestinal bleeding 11
Sepsis 11
Irregular menses 8
Coronary insufficiency 5
Peptic ulcer identified by X-ray 3
Bleeding from urinary tract 3
All patients in this study had diagnosed anemia.
For the purposes of this study, hypertension during
dialysis was defined as diastolic pressure over 110 during
dialysis or if predialysis pressure near 110 an increase of
10 points during dialysis. Hypotension during dialysis was
similarly defined as a diastolic drop below 60 during
dialysis.
r" ' ~ 183
i
Blood pressure control was one of the most promi
nent medical problems during dialysis for these patients.
j Of the patients in this study 38% had hypertension and 27%
|had hypotension during dialysis in the three months preced
ing this study.
Neuropathy was also a prominent problem. Of the
patients in this study, 32%, had sensory peripheral j
neuropathy and 19% had motor peripheral neuropathy within !
j
the three months preceding this study. Motor peripheral j
neuropathy correlated positively, r = .70, with sensory !
!
peripheral neuropathy. j
Diagnosed pruritis was found in 227, of the j
patients. A majority of the patients, or 70%, stated that j
they had been bothered by intense itching skin at some time
since beginning hemodialysis. Patients reported that
during the three months preceding this study intense itch
ing skin had been: (a) absent for 41%, (b) less severe for
|35%, (c) the same for 8%, and (d) more severe for 16% of
the patients than previously during home dialysis.
Pruritis was most correlated to diagnosed
neuropathy. Pruritis correlated positively with sensory
peripheral neuropathy, r = .62, and with motor peripheral
neuropathy, r = .58. Diagnosed pruritis was also posi
tively correlated to nonsuitability of transplant, r = .58.
Some pruritis may be age related since advanced age was a
|frequent basis of nonsuitability of transplant.
184 j
Shunt Information
. j
i
i
Location. A majority of the patients, or 57%, had !
,the shunt located in the arm. Almost half of the patients
with an arm shunt, 477,, had the shunt located in the
|preferred arm used for writing.
I
Infections. The majority of the patients, or 78%,
had no shunt infections during the three months preceding
this study. Shunt infections during this time interval i
I
ranged from 0 to 1 with a mean of 0.2 (SD = 0.42; SEm = j
0.07). |
I
j
Shunt clots. The majority of the patients, or 73%,, j
I
had no hospital declotting procedure of their shunts during
the three months preceding this study. Hospital declotting
frequency ranged from 0 to 2 times with a mean of 0.3
(SD » 0.45; SEm = 0.07).
Most patients, or 697,, had not declotted their
shunt at home during the three months preceding this study.
Of the 31% of the patients who had declotted their shunt at
home, the number of times ranged from 1 to 8. Of the
patients in this study, 11% declotted their shunt 4 or more
times. For all the patients the mean number of self-
declotting was 0.9 (SD = 1.82; SEm = 0.03).
i
Surgical repairs. The majority of the patients had
no arterial repair, 81%, and no venous repair, 73%, of
185
their cannula during the three months preceding this study.
Surgical repairs to the venous line outnumbered surgical
repairs to the arterial line by almost 3:2.
Arterial repairs to the cannula ranged from 0 to 1
time in the preceding three months with a mean of 0.2
(SD = 0.40; SEm = 0.06). Venous repairs to the cannula
during this time ranged from 0 to 1 time with a mean of 0.3
(SD = 0.45; SEm » 0.07).
A breakdown of the percentage of occurrence of
shunt problems in the preceding three months were as
follows:
Per Cent
Problem Occurrence
Declot by patient 31
Declot by hospital 27
Venous repair 27
Infection 22
Arterial repair 19
Clotting in the cannula line was the most frequently
encountered shunt problem.
Dietary Adherence
Salt and water excess. Most patients, or 73%, had
a problem with salt and water excess as determined by a
frequent weight loss greater than 1 kilogram during
dialysis. ________
186 |
The range of average weight loss varied from 0.8 to;
8.1 lbs. with a mean of 3.16 lbs. (SD = 1.53; SEm = 0.25).
| The greatest absolute weight loss on any single
I
|dialysis run during this time ranged from 2 to 15 lbs. with
!a mean of 5.9 lbs. (SD = 3.0; SEm = 0.49).
I
Food binges. Only 11% of the patients had a pre
dialysis serum potassium greater than 6.5 on a routine
laboratory test during the three months preceding this j
study. This would indicate that food binges was not a |
i
problem with the patients in this study. j
Malnutrition. A routine serum albumin below 3.5, j
i
exclusive of illness or infection, within the past three j
months was used to roughly assess malnutrition. Of the I
patients in this study, 23% had a serum albumin below 3.5.
However, data were missing for 30% of the patients.
Therefore, it cannot be determined at this time if adequate
j
[nutrition is a prominent problem for this patient
ipopulation.
Adequacy of Dialysis
A rough attempt was made to assess adequacy of
dialysis through frequency of critical measures on biochem
ical laboratory tests taken within the preceding three
jmonths of this study. Although adequacy of dialysis is a
function of many variables including: (a) body weight,
1 8 7 j
(b) length and frequency of dialysis, and (c) type of
equipment, critical biochemical measures on laboratory
:tests are an indirect indication of inadequacy of dialysis.
j The occurrence of BUN greater than 90.0 was found
|for 46% of the patients in this study.
| The occurrence of serum creatine greater than 16.0
was found for 35% of the patients in this study.
The occurrence of predialysis uric acid over 9.0 |
[
was found for 33% of the patients in this study. j
i
The occurrence of predialysis phosphate over 10.0 j
was found for 24% of the patients in this study. j
Rehabilitation Information
I
I
Occupation. The majority of the patients, or 54%,
worked less hours following home dialysis than before home
dialysis while 46% were able to work the same number of
hours as before dialysis.
Most patients, or 68%, did not change their occupa-
!tion because of dialysis while approximately one-third, or
32%, have changed their occupation.
Current employment varied for the patients and
included: (a) unemployed, 22%, (b) part-time (1-32 hours
per week), 27%, (c) full-time (33-40 hours per week), 24%,
and (d) more than 40 hours per week, 27%. Approximately
half of the patients were working at a full-time capacity.
| “ “ ' ~ “ ~ 188 1
t i
| The majority of the spouses, or 68%, were employed ;
!full-time while 9% of the spouses worked part-time and 23%
Iwere not employed. Of the married male patients, 71% had
employed wives. j
More employed spouses were found in this study than
in others. The fact that most patients in this sample had
ino children tinder 16 years of age may account for the
Ihigher spouse employment rate. However, 66% of the wives
! i
|with younger children were also employed. i
f
Following dialysis there was no shift in employment
| for 76%, of the spouses while 12% now work more hours and
ianother 12% now work fewer hours. In the two cases where a i
i :
!male patient’s wife had become employed since dialysis |
iwhere previously a housewife, both husbands stated that
they were happy with their wives working.
Activity. A majority of the patients, or 76%, were
less active than before dialysis. For the less active
jpatients, 82% were unhappy about this. The other 18% j
accepted their decrease in activity.
| A minority of the patients, or 30%, have been able
I to fit their dialysis schedule around their usual activi-
i i
ities. They find that dialysis does not interfere with i
| ;
jtheir activities. j
! i
I The majority of the patients, or 70%,, scheduled i
| !
iaround dialysis. Where this occurred 77% of the patients j
189 ;
who scheduled around dialysis were unhappy about the '
1
confinement of plans and activities.
! Sexual potency. In comparing the patients1 current
I
|sexual performance to that before dialysis, sexual perform
ance had: (a) ceased for 30%, (b) decreased for 41%, (c)
stayed the same for 24%, and (d) increased for 5% of the
patients (both females).
Thirty per cent of all the patients, or 43% of the j
males, are impotent. The range of months of impotency for
|
this group varied from 6 to 48 with a mean of 24.7 months.
The majority of the patients, or 73%, viewed their j
current sex life as satisfactory. Sexual satisfaction was j
positively correlated to years of marriage, r = .77, and to!
current marital happiness, r = .64. Patients' current
sexual satisfaction was less related to actual performance,
r = .54.
i
Since years of marriage was strongly correlated to
age, r = .76, it appeared that older patients were less
I concerned about any sexual inadequacies. Also the quality
of the current marital relationship seemed to be a strong
determinant in the acceptance of sexual decline. Happier
couples appeared to give it less importance.
I The majority of the spouses, or 68%, stated that
i
jtheir current sex life was satisfactory. However, 32% of
the spouses stated that the patient was less sexually
~~ 190 j
attractive than before dialysis. The sexual attractiveness!
of the patient was most correlated to the current health ofj
the spouse, r = .55.
Spouse sexual satisfaction was positively corre
lated to: (a) ease of being able to express feelings to
the patient, r = .73; (b) self-confidence about assisting
with dialysis, r = .64; and (c) lack of increased irrita
bility in the patient, r = .57. This might indicate that
in a working relationship where the partners can express
|
themselves freely and where the patient is not more j
i
irritable, the spouses feel more self-confident and more
contentment in various areas including the sexual aspect of!
their marriage.
Seventy per cent of the patients were informed by a
staff member, usually the physician, that impotency or
decreased sexual activity commonly occurs with dialysis.
A similar proportion of 70% of the impotent males were
given this information. Since a higher proportion of this
information was not found among the impotent patients,
expectational set from the staff did not appear to be a
basis of impotence.
Psychological Well-being
191
i
General happiness. The results of patients rating I
jtheir current happiness compared to the general population
|included: (a) happier for 38%, (b) average for 46%, and
|
j (c) more unhappy for 16%.
The results of patients rating their happiness
compared to other kidney patients included: (a) happier
for 54%, (b) average for 41%, and (c) more unhappy for 5%.
As in the findings by Wright et al. (1966) the j
majority of the patients rated themselves as much happier |
in comparison to other home patients than to the general i
population. This supports the conclusion by Wright et al. j
of denial at a conscious level of personal dissatisfaction j
with being a kidney patient and of seeing the kidney group
as less happy but denying this in reference to himself.
However, these ratings of happiness were lower in both
I
;general population and patient comparisons than in the
Wright study which indicates less use of denial in patients
iin this study.
Spouses completed similar ratings. The results of
spouses rating their happiness compared to the spouses in
the general population results included: (a) happier for
50%, (b) average for 4470, and (c) less happy for 6%. These
I
i ratings were similar to the patients' ratings.
| In contrast to the patients, the spouses had a
[lower happiness rating when comparing themselves to other
192 !
)
spouses of dialysis patients. Although none of the spousesi
irated themselves as less happy than other spouses of
;dialysis patients, 62% rated their happiness as average and
38% rated themselves as happier.
| It is revealing that the spouses would rate them-
j
iselves happier in comparison to the general population than
to other spouses of dialysis patients. This reflects an
awareness, and lack of conscious denial, of personal j
dissatisfactions associated with being a spouse of a kidney I
patient. |
i
The majority of the spouses, or 81%, found the
patients more unreasonable, self-centered, short-tempered,
i
and demanding since dialysis. Increased temperament on the!
part of the patients may contribute to the spouses' feel
ings of being less happy than other spouses of dialysis
patients.
| Marital happiness. In comparing their marital
i
ihappiness following dialysis to marital happiness before
dialysis, the majority of the patients, or 79%, felt no
difference in happiness while 21% felt there was a decrease
in marital happiness. Similarly, 72% of the spouses felt
no difference in happiness while 28% were unhappier. One
ispouse was happier.
Marital happiness pre- and postdialysis was posi
tively correlated for both the patients, r = .84, and for
193 !
;the spouses, r = .79. This indicates that little shift in !
direction occurred for either patients or spouses. Marital
I happiness has decreased for some dialysis families with the
spouses being slightly more affected in decrease of happi
ness.
;Effects of Dialysis on the Spouse
The majority of the spouses, or 84%, currently felt
* I
closer to the patient than before dialysis while 16% of the |
j
spouses now felt further apart since dialysis. Of the j
spouses who felt closer to the patient, 46% felt much closer
now while 38% felt slightly closer. Current closeness to I
the patient correlated positively with current marital
happiness, r = .56.
The majority of the spouses, or 68%, felt that they
■ got along the same with the patient as compared to before
idialysis. Thirteen per cent of the spouses felt that they
:now got along better. Nineteen per cent of the spouses
i
j felt that they now got along poorer.
The majority of the spouses, or 59%, spent more
time with the patient than before dialysis. Forty-one per
cent of the spouses spent approximately the same time with
the patient as before dialysis. None of the spouses
currently spent less time with the patient than before
dialysis.
Of the 49% of the spouses who have had to drop
194
social or recreational activities because of dialysis, 70%
|missed the activities greatly.
! For the spouses, drop in social activities was
I
|positively correlated to missing the activity, r = .92,
and to frustration in canceling plans at the last moment
because of the patient's unexpected ill health, r =» .55.
;The amount the activity is missed was also correlated to
the amount of free time the spouse spends with dialysis
work, r = .51, and with inability to express feelings to
the patient, r = .57. This would indicate that spouses
should be encouraged not to give up outside activities or
to become too involved with dialysis work in order to
maintain their own equilibrium and to avoid a source of
resentment.
Spouses spent a large proportion of their free time
in dialysis work, such as cleaning the equipment, preparing
special foods, or helping the patient with self-care. The
breakdown of free time involved in dialysis work included:
|(a) 40 to 80% of free time for 36% of the spouses, (b) 21
jto 40% of free time for 32% of the spouses, and (c) 0 to
i
19% of free time for 32% of the spouses.
A large number of the spouses, 43%, have had to
take a more active role in managing the home, caring for
|the children, or in making decisions. Of this group 70%
were unhappy about this shift in roles and 73% found it
difficult to handle this additional responsibility.
. . . . 195
Spouses who had to assume a more active family role were !
generally dissatisfied. There was a positive correlation !
I of r = .90 between more active family role and unhappiness
!about this role shift. Spouses who were unhappy about the
i
!additional responsibility also had more difficulty in
i
Ihandling this additional responsibility, r = .74, and in
expressing their feelings to the patient, r = .62.
A minority of the families, or 19%, never had to j
j
cancel social activities due to the patient's sudden ill |
i
i
health. For the 81% of the families who had to suddenly !
I
cancel plans due to the patient's ill health, 53% of the j
spouses found the last-minute cancellations frustrating. !
A majority of the spouses, or 73%, have had to I
schedule their activities around the dialysis schedule.
Of this group, 52% were unhappy about this. Dialysis did
not interfere with the activities of 27% of the spouses.
Of the families with children, 21% of the spouses
I felt that dialysis had caused significant problems for the
;children.
j Spouses were asked to rate their current health
compared to their health before dialysis. The majority, or
92%, felt that their health was as good as before dialysis.
Yet the following symptoms were checked as more severe than
before dialysis: (a) anxiousness, 59%, (b) tiredness, 57%,
|(c) depression, 32%, (d) sleep problems, 24%, (e) headaches,
11%, (f) colds, 11%, and (g) regular medication for nerves
and sleep, 8%. j
Spouses whose health remained the same experienced j
more anxiety since dialysis, r = .56, than spouses whose
health was worse since dialysis. More anxiety was posi
tively correlated to regularly taking medication for nerves
;or sleep, r = .62. Regular medication for nerves and sleep
was positively correlated to spouses' attitudes about
dialysis of the benefits outweighing the hardships, r = .52.
On the other hand, spouses who rated their current |
|
health as poorer had: (a) more colds, r = .53; (b) more i
headaches, r = .85; and (c) more depression, r = .52.
i
Spouses who were more depressed since dialysis and who had j
more headaches tended to see more hardships in dialysis,
r = .53 and r = .56, respectively. |
It appeared that spouses who gave a higher rating
to the benefits of dialysis outweighing the hardships had
less physical symptoms since dialysis such as colds, head-
iaches, or depression. However, they experienced more
!anxiety for which they tended to take medication. Perhaps
increased anxiety is a realistic, constructive adaptation
to the stresses of dialysis for the spouse.
Although family dissension can arise from the
demands of the patient being incompatible to the desire of
|the spouse to help the patient, this did not appear to be a
major problem with the families in this study. The major
ity of the patients, or 78%, rated spouse help as generally
[ 197” j
equal to the amount of help desired. The majority of the
I
spouses, or 81%, felt that the patient generally wanted j
Ihelp about equal to the amount they wanted to give.
i
!
| In weighing the value of the benefits of dialysis
I
against the hardships involved, spouses were more positive
ithan the patients. All spouses felt that the benefits of
!dialysis outweighed the hardships. The majority of the
spouses, or 81%, felt that the benefits greatly outweighed
the hardships while 19% felt that the benefits somewhat j
outweighed the hardships. j
i
Patients, on the other hand, responded to this j
question as follows: (a) benefits greatly outweigh the |
hardships, 69%, (b) benefits somewhat outweigh the hard
ships, 147o, (c) hardships equal to the benefits, 14%, and j
(d) hardships outweigh the benefits, 3%. This may indicate
more denial and repression of anger towards the dialysis
|life-style on the part of the spouses since patients tended
i to view themselves as happier than other patients while
I spouses tended to view themselves as less happy than other
|spouses of dialysis patients.
Psychological Test Results
WAIS. The WAIS Full Scale score ranged from 70 to
131 with a mean of 105.4 (SD = 13.34; SEm = 2.19). The
WAIS Verbal Scale score ranged from 73 to 134 with a mean
of 106.0 (SD =» 13.72: SEm = 2.25). The WATS Performance__
;Scale score ranged from 70 to 136 with a mean of 103.8 (
j (SD ** 13.01; SEm » 2.14) .
j The intercorrelations on the WAIS were as follows:
(a) Full Scale and Verbal Scale, r =» .96, (b) Full Scale
and Performance Scale, r = .91, and (c) Verbal Scale and
!Performance Scale, r * .75.
Organic brain damage has been found in chronic
i
hemodialysis patients with good uremic control (Barber j
et al., 1963; Short & Wilson, 1969). The WAIS Verbal Scale !
minus Performance Scale differential ranged from +34 to -16
with a mean of +2.2 (SD = 9.49; SEm = 1.56). Only 5% of
the patients in this study had a Verbal Scale 12 to 14
points higher than the Performance Scale. j
The WAIS differential of the Performance Scale 12
to 34 points lower than the Verbal Scale was found for 39%
of the patients in this study who were on home dialysis
I longer than 21 months. One patient on home dialysis only
|11 months also showed this pattern. The results of this
|study would tend to confirm the findings of a WAIS organic
brain damage pattern for many patients on chronic hemo
dialysis .
MMPI scales distribution. The distribution of the
MMPI scales was as follows:
|L Scale
]
i
JK Scale
F Scale
iScale 1
i
[Scale 2
I
i
!
jScale 3
I
| Scale 4
Scale 5
Scale 6
! Scale 7
[Scale 8
|
jScale 9
i
Scale 0
199 1
range 1-11; M = 4.5, or T score = 52 (SD = 2.28;
SEm =0.37)
range 6-24; M =» 14.5, or T score = 54 (SD = 4.17;
SEm = 0.69)
range 0-23; M = 6.3, or T score = 59 (SD =4.49;
SEm = 0.74)
(Hs) : range 11-33; M => 20.4, or T score = 73 !
(SD » 4.93; SEm = 0.81) j
_ |
(D): range 17-48; M = 27.7, or T score = 77 j
(SD = 6.54; SEm = 1.07)
_ |
(Hv): range 16-38; M = 28.1, or T score = 72 !
(SD = 5 .28; SEm = 0.87) j
(Pd): range 9-33; M = 21.2, or T score = 53 j
(SD = 5.21; SEm = 0.86) |
_ i
(Mf): range 16-46; M = 28.6, or T score = 57 |
(SD = 7.89; SEm = 1-30)
(Pa): range 3-20; M = 9.7, or T score = 54 j
(SD = 3.95; SEm = 0.65)
(Pt): range 16t43; M = 28.7, or T score = 62
(SD » 5 .66; SEm = 0.93)
i
(Sc): range 12-47; M = 27.5, or T score = 60 |
I
(SD » 7.31; SEm » 1-20)
(Ma) : range 11-28; M =» 18.0, or T score = 53
(SD = 4.36; SEm = 0.72)
(Si): range 11-31; M = 22.1, or T score = 47
(SD - 5.62; SEm = 0.92)
; "" 200
Ego' Strength Scale: range 18-51; M = 38.6 (SD = 7.04;
SEm - 1.16) !
! Dependency Scale: range 3-39; M = 21.4 (SD = 9.80;
! SEm - 1.61)
|
i The T scores of this distribution was based on the
|
| male profile. Therefore, for female patients Hs, D and .Sc
■ T score values would be lower while Hy and Ft T score
i
values would be higher.
No attempt at finding MMPI patterns was undertaken ;
at this time. However, when all the profiles are pooled
together a 2-1-3 pattern emerges in the 72-77% range on T
scores with all other scales lower and in the 47-62% range.
This would indicate a neurotic pattern with depression,
worry over health and bodily functions, and involvement
with physical symptoms. This pattern is understandable
since the patients are continually involved with the phys-
;ical aspects of dialysis and with their medical condition.
IHv correlated positively with HS, r = .69, and with D, r =
.53. Pt correlated positively with D, r = .70, and with
1Hv. r = .53. The 2-1-3 pattern was found in 32% of the
|
individual patients.
On the profile pattern D was the highest scale for
154% of the patients. A psychosomatic V pattern as the
!
|highest scales was found for 24% of the patients. Other
|
I combinations of 1-2-3 as the highest scales were found for
201 j
22% of the patients. Another 22% of the patients had other;
high scales or combinations. •
| N e u r o t i c - p s y c h o t i c c l a s s i f i c a t i o n . The d i a g n o s i s
i
j o f p s y c h o t i c v s . n e u r o t i c from t h e MMPI p r o f i l e w as made
i
using the High Point rules (Goldberg, 1965). In applying
I
the High Point rules, highest scales of 1, 2, 3, or 7 on
the profile constitute a neurotic diagnosis while highest j
scales of 4, 6, 8, or 9 constitute a psychotic diagnosis.
The majority of the patients, or 79%, fell in the neurotic i
category. Four patients, or 11%, fell in the psychotic j
category. This is an admittedly crude assessment. j
However, if these results are indicative of the true state
of the patients' psychological make-up, then they are ;
i
holding up under the stresses of dialysis.
Sc w as p o s i t i v e l y c o r r e l a t e d w i t h : ( a ) P t , r =
.87, (b) Pd, r = .72, (c) Factor A, r = .65, (d) Pa, r =
!.58, and ( e ) D e p e n d e n c y , r = .56. T h is i n d i c a t e s t h a t
jpatients with strong worry, feelings of discomfort, suspi-
]
|cion, and dependency are more ego-constricted, emotionally
j
idetached, and socially alienated.
Factors A and R. Welsch (Dahlstrom & Welsch, 1960)
found two basic factors in the MMPI. Factor A involves
|degree of felt disturbance including: personal discomfort,
I distress, anxiety, or general emotional upset. Factor R
|_invo_lves denial, rationalization, and lack of effective____
I 202 !
i ;
; I
self-insight.
i I
The distribution of these factors for the patients
;in this study was as follows. Factor A: range 0-29; M =
12.7 (SD = 8.56; SEm = 1.41). Factor R: range 12-30; M =*
20.9 (SD = 4.35; SEm = 0.71). It appears that denial and
;rationalization was more prominent in these patients than
awareness of distress and anxiety. This result confirms
previous findings of high denial and rationalization in
hemodialysis patients.
Factor A had a high positive correlation with the
Dependency scale, r = .91, which indicates that patients
!with little denial and rationalization are more dependent.
'Denial and rationalization are important adaptive defenses
i
;in hemodialysis patients for the development of self-
isufficiency and self-responsibility. This is further
indicated by the fact that the Ego strength scale is nega
tively correlated with the Dependency scale, r = -.83. j
i
; I
The necessity of strong denial for successful j
; |
adjustment to hemodialysis is also confirmed through the K j
iscale correlations. Scale K correlated positively with Ego
strength, r = .67. Scale K correlated negatively with:
pFactor A, r = - .76; (b) Depression, r = -.72; and (c) Si.
r = -.67. This would indicate that persons with high
personal defensiveness experience fewer feelings of discom-
;fort, anxiety, or depression.
203 j
P-F Study. Patients obtained the following distri- |
butions on this test: I
I Extrapunitive (E) : range 10-79; M = 46.7 (SD = 15.52;
| SEm = 2.55)
!Intrapunitive (1): range 6-42; M = 26.9 (SD = 8.84;
| SEm = 1.45)
Impunitive (M): range 0-48; M = 26.5 (SD = 10.68;
SEm = 1.76)
i
Obstacle-Dominant (O-D): range 8-40; M = 19.6 (SD = 8.19; I
SEm = 1-35) i
Ego-Defensive (E-D): range 24-79; M = 55.1 (SD = 13.10; !
i
SEm = 2.15)
Need-Persistent (N-P): range 2-50; M = 25.2 (SD = 13.99;
i
SEm = 2.30)
Group Conformity Rating (GCR): range 41-81; M = 63.4
(SD = 11.06; SEm = 1-82)
The majority of the patients ranked highest in an
S
extrapunitive (E) direction of aggression (73%) and an ego
defensive (E-D) type of reaction to frustration (80%). The
distribution for direction of aggression was higher on E
and lower on M than the distribution for a normal popula
tion. However, the distribution of direction of aggression
|closely approximated that found in a normal population.
'The correlation of E to ED was r = .83.
I
204 |
The primary combinations and frequency in the j
patient population were as follows: (a) E-ED = 25, (b)
E-NP = 1, (c) E-OD = 1, (d) I-ED =2, (e) I-NP =2, (f)
jM-ED = 4, and (g) M-NP = 2. Only five of the patients were
|solution-oriented and only one patient was fixated on the
obstacle.
In general these patients responded to frustration
with blame or hostility turned against some person or thing i
: j
in the environment and by denial of responsibility for the
frustrating situation. This heavy use of projection of
hostility is ego-constricting as evidenced by the small
number of patients who are problem-solving oriented. In
practical terms their use of projection of hostility would
mean that they would be "difficult" with the staff and in
interpersonal relations. Many spouses found the patients
more irritable and difficult to get along with since
dialysis. Initial hostility, frequently masked in passive-
iaggressive behavior, was observed frequently in these
patients by the Investigator.
j
Body Image. The Body Image test (Schwab &
Harmeling, 1968), involving ranking of attitude towards
bodily parts and functions, was administered to the patients
in this study. The body image scores ranged from a low of
i2.2 to a high of 4.8 on a five-point scale with a mean of
1 3.33 (SD = 0.66; SE^ » 0.11).
. . . 205.1
On a sample of medical inpatients Schwab and
Harmeling obtained a range of 1.40 to 5.00 with a mean of j
13.45 and SD of 0.67. The patients in this study then had
I an average body image that was slightly lower but
|comparable to medical inpatients. They expressed more
;dissatisfaction with their bodies than nonhospitalized
healthy persons.
Many of the patients, or 44%, expressed generalized
dissatisfaction with their bodies and gave negative
responses to many body parts and functions. Schwab and 1
Harmeling felt that this reflects an extension of negative
feelings towards the body as a whole resulting in a devalued
i
body image indicative of emotional distress. i
Body image was negatively correlated to the WAIS |
Full Scale score, r = .53, and negatively correlated to the
MMPI Ego Strength scale, r = -.63. This indicates that
ipatients who are bright or have good ego function tended to
experience more dissatisfaction with their bodies. This
i
I could be a result of greater sensitivity and awareness and
i
|of less reliance on defense mechanisms.
j
| On the other hand, body image was positively corre
lated to the following MMPI scales: (a) Factor A, r = .74,
(b) Pt, r = .70, (c) Dependency, r = .64, (d) Pa, r = .62,
|and (e) Pd, r = .57. This would indicate that the depend
ent, self-critical patients who are aware of personal
distress, anxiety, and worry tend to feel more satisfaction
with their bodies. The basis of this paradox may be a j
strong denial defense in operation. j
j In comparing the patients' rating of their kidneys
;to the average body image rating, scores ranged from a low
bf -3.4 to a high of 1.6 with a mean of -1.17 (SD = 1.29;
SEm = 0.21). It would be expected that the patients would
have more dissatisfaction with their kidneys than with
their bodies as a whole. However, 22% of the patients felt
more satisfaction with their kidneys than their bodies in
general. This is an interesting finding. It is unknown at
this time if this indicates something beyond marked denial.
Mechanical Comprehension. On Bennett's Mechanical
Comprehension Test (Form AA), patients scored from a low of |
0 to a high of 55 with a mean of 33.8 (SD = 14.80; SEm s *
2.50) .
A combined operators' score was also obtained. If
Ithe patient or another person primarily operated the
jdialysis equipment, a single score was used. Where the
patients shared the operation, both scores were averaged
into a single combined index. The range varied from a low
of 14 to a high of 57 with a mean of 34.7 (SD = 11.88;
SEm - 1.95) .
Both the patients' single score and the combined
operator score were at the 33 and 35 percentile for high
school graduates, respectively.
; 207
The patients' Mechanical Comprehension score had
i
I the highest correlation to the WAIS Full Scale score, r =
j .73. The Mechanical Comprehension Test was also positively
correlated to the Verbal Scale, r = .68, and to the
Performance Scale, r = .67. There was only a modest
correlation, r = .58, between the patients' Mechanical
Comprehension score and the combined operator Mechanical
Comprehension index. This would indicate that some
patients high in mechanical aptitude had helpers low in
mechanical aptitude and vice versa.
CHAPTER IX
RESULTS OF MULTIPLE REGRESSION ANALYSES
Introduction
! Following the compilation of the descriptive
statistics, 175 separate multiple regression analyses were
undertaken for the purpose of finding predictors to each of
the many medical problems and to the adaptational and j
rehabilitational aspects of hemodialysis. !
!
Since many of the variables in dialysis are inter- j
related (such as dialyzer and hours of dialysis per week), j
the utility of the multiple regression analyses was the
i
ability to select a subset of relevant predictors which are ;
analyzed simultaneously. In deriving a truer meaning of the
relationship of a predictor to a criterion variable, the
interrelationships of the predictor variables to each other
lare parceled out. Spurious predictor variables are then
jeliminated. These variables appear to correlate highly
jWith the criterion because they are related to a "true"
i
predictor variable that is correlated with the criterion.
Due to the magnitude of the analyses, it would be
impractical to comment on each analysis. Therefore, this
section will be limited to a discussion of some of the
208
| 209 j
j i
major findings on the basis of significant t : tests and
F tests.
i i
| I
Patterns of Results
| ;
i The results of the multiple regression analyses
fall into four categories: j
! Case 1. (No prediction--nonsignificant F test and j
^nonsignificant jt tests.)
In this most frequent result, the 1 : value on the
i
regression coefficient for each predictor was not signifi- !
Jcant at the p. < .05 level and the F value on the analysis
i :
of variance for the multiple regression was not significant ;
at the p < .05 level. None of the predictor variables were
'strongly separately related to the criterion variable. The
: |
predictors together did not sufficiently account for the
Variance of the criterion measure.
: I
: I
t
Case 2. (Partial prediction--significant F test
and nonsignificant _t tests.) |
In a few rare cases, the predictors together I
i i
significantly accounted for the variance in the criterion |
| I
variable. However, none of the t : tests for any of the
i
predictors were significant at a £ < .05 level. In this
i
pase the predictors that related strongly to the criterion
i
were located, but they were strongly intercorrelated and
shared predictive power.
| 210 |
Case 3. (Partial prediction--significant t tests j
and nonsignificant F test.)
| This was the most commonly found positive result.
Predictor variables highly related to the criterion were
|located. However, they did not sufficiently account for
|the variance of the criterion for two possible reasons:
i(a) other predictors in the regression were poorly chosen
and irrelevant and tended to dilute the predictive power of
the relevant predictor, or (b) not enough of the signifi- !
i
i
cant predictors were included to account for the variance j
of the criterion at the p < .05 level. j
i
Case 4. (Full prediction--significant F test and
significant t : tests.)
In this less frequent case, the significant pre-
|dictor variables were located and they sufficiently
; accounted for the variance in the criterion measure . No
|relevant variables were overlooked. Reliable prediction
| occurred.
i
211
Multiple Regression 1. Use of Psychological
Tests to Predict General Hemodialysis Adap
tation and Rehabilitation Criteria
Predictor variables. The following 13 psycholog
ical test scores were analyzed simultaneously and applied
|as an intact set to each of the criterion variables in 14
^separate multiple regression analyses:
1. WAIS Verbal Scale score.
2. WAIS Performance Scale score.
3. MMPI Factor R scale.
4. MMPI Factor A scale.
5. MMPI Dependency Scale.
6. MMPI Ego Strength Scale.
7. Neurotic-psychotic MMPI classification.
8. Patient Mechanical Comprehension.
9. Combined operator Mechanical Comprehension.
10. P-F Study Group Conformity Rating.
11. Body Image score.
12. P-F Study E-I-M.
13. P-F Study E-ED vs. other combination.
Criterion Variables. Criterion variables included
adaptation and rehabilitation factors. Adaptation variables
included: (a) transient and chronic medical symptoms, (b)
dietary control, and (c) shunt problems. Rehabilitation
variables included information on: (a) marital and general
! 212
happiness, (b) employment, and (c) sexual performance.
A list of the 14 general criterion variables is
i
!
presented below under the category of results that occurred
I
|for the regression analyses.
I
! Case 1 (no prediction--low F and low t. tests) .
I ----------- -----------------------------------
1. Differential of marital happiness pre- and post
dialysis.
2. Current happiness compared to people in general.
3. Current happiness compared to other dialysis
patients.
4. Total shunt infections in the past three months.
5. Total chronic medical problems in the past three
months.
6. Total transient symptoms during dialysis.
7. Total transient symptoms following dialysis.
8. Less activity following dialysis.
Case 3 (partial prediction--low F and high j: tests).
9. Current level of sexual performance compared to
predialysis level.
10. Satisfaction with current sexual performance.
11. Current hours worked per week.
12. Decrease in work hours following dialysis.
j __ 213 !
■ i
Case 4 (full prediction--high F and j: tests). |
13. Laboratory tests indicating dietary nonadherence !
and dialysis inadequacy.
14. Total shunt problems in the past three months.
| Discussion of results. None of the psychological
;test scores in this predictor subset were able to differen
tiate patients on: (a) marital happiness, (b) ratings of
self-happiness, (c) quantity of shunt infections, (d) j
chronic medical problems, or (e) transient symptoms during |
and after dialysis. !
i
These test scores were able to differentiate I
i
patients on: (a) employment, (b) sexual performance and
i
satisfaction, (c) total shunt problems, and (d) dietary j
nonadherence. The significant t tests for each of these
criterion variables are presented in Table 1.
Significant F tests indicating full prediction were
I obtained for dietary adherence and total shunt problems.
i 1. Sexual performance was separately predictable
from the Body Image score, the MMPI Ego Strength scale, and
the MMPI Factor R scale (jt tests =* p < .05; Table 1). High
scores on any of these tests would indicate current sexual
performance adequate and equivalent to predialysis levels.
Current sexual performance was then separately related to:
(a) body satisfaction, (b) ego strength, and (c) high use
TABLE 1
SIGNIFICANT t VALUES ON THE REGRESSION COEFFICIENT
FOR PSYCHOLOGICAL TEST PREDICTORS OF GENERAL
ADAPTATION AND REHABILITATION CRITERIA
Criterion Variable Predictor Variable t_ Value
Sexual performance
Body Image
MMPI R
MMPI Ego Strength
2.05*
2.17*
2.68*
Sexual satisfaction Patient Mechanical -2.34*
Employment MMPI Factor A -2.42*
Decrease work hours
WAIS P
MMPI Factor A
2.09*
2.27*
Poor diet-dialysis
WAIS P
MMPI R
MMPI Dependency
MMPI Ego Strength
Combined Mechanical
P-F GCR
P-F E-ED vs. other
2.21*
-2.69*
-2.79**
-3.82**
-2.46*
-3.29**
-3.26**
Total shunt problems
P-F E-I-M
P-F E-ED vs. other
-3.38**
2.53*
t (.05/2;36) = 2 .03 *p < . 05
t (.01/2;36) = 2.72 **p < .01
I
i
^ 215 !
of denial and rationalization. Since the F test was not
significant, other unknown variables may also account for !
|the variance in sexual performance following dialysis.
2. Satisfaction with current sexual performance
|
was related to a low patient Mechanical Comprehension score
|
: (t. test = p < .05; Table 1). This interesting predictive
finding may indicate that patients low in mechanical apti-
j
tude are less compulsive and tend to be more self-satisfied j
in all areas of personal achievement. Since the F test was j
I
not significant at the p < .05 level, other unknown vari- I
ables may also account for sexual satisfaction. i
j
|
3. Current employment was related to a low MMPI j
Factor A score (_t test = p < .05; Table 1). Patients who j
are less aware of physical symptoms and personal discomfort
tended to work more hours per week. Since the F test was
not significant, other unknown variables may also account
jfor current employment.
I
I
4. Decrease in work hours following dialysis was
|separately related to high scores on the WAIS Performance
I Scale and to the MMPI Factor A score (t. tests = p < .05;
!
jTable 1). Patients who scored higher on nonverbal rather
j
than verbal intelligence are probably persons who had
manual occupations and who may have had to change occupa
tions due to dialysis. Patients who were more aware of
: 216 !
physical discomfort and physical illness may feel too ill
to work to full capacity. Since the F test was not 1
significant, other unknown variables may also account for
i
! current employment.
5. Laboratory tests indicative of nonadherence to
diet and dialysis inadequacy. The F test on this regres
sion analysis was significant at the p < .05 level which
indicates that full prediction of dietary nonadherence was
obtainable from these test scores. These test scores
|
significantly account for the variance among patients with i
i
good or poor dietary control and with adequate dialysis. •
i
Predictor variables with t tests significant at the |
p < .05 level included a high score on the WAIS Performance j
scale and the MMPI Factor R score and a low score on the
operators' combined Mechanical Comprehension score
(Table 1) . Predictor variables with t, tests significant at
‘the jd < .01 level include low scores on the MMPI Dependency
and Ego Strength scales and a low score on the P-F Group
i
iConformity Rating. Another predictor at the p < .01 level
was the P-F Study combination other than E-ED.
Patients higher on nonverbal than verbal intelli
gence had more problems with diet control and dialysis
adequacy. Patients high in dependency, ego strength, and
denial and rationalization had less problems with diet
i
control. Patients with a high combined operators' score on
217
mechanical comprehension had fewer problems with diet
control and proper dialysis. These variables suggest that
'patients who are either dependent, exacting, or have good
i
|ego strength and adaptive defenses are more careful about
jwatching their food intake and in obtaining adequate
jdialysis.
The P-F Study was predictive at the p < .01 level.
Patients who score low on group conformity and who have an
extrapunitive direction of aggression to frustration had !
I
more problems with dietary adherence.
It was initially hypothesized that patients high on j
an intropunitive direction of aggression would take out
their aggression on themselves and thereby have a higher j
incidence of shunt or dietary problems. However, it appears;
that the nonconforming patient who projects hostility
externally has less cooperation with shunt, dietary, and
|dialysis needs. Perhaps patients who externalize hostility
Sand who score low on conformity have poorer impulse control
and therefore more difficulty in adhering to a dialysis
regime. More importantly, these externalizing patients may
have excessive, maladaptive denial. They may totally deny
the illness and its severity which blocks cooperation and
results in more shunt, diet, and dialysis inadequacy
problems.
218 !
j
6. Shunt problems. The F test on the regression
analysis was significant at the p < .05 level which indi- j
j i
;cates full prediction of higher incidence of shunt problems
j
jwas obtainable from scores on the P-F Study. Patients who
|scored high on E and expressed aggression to frustration
I
externally had more shunt problems. The _t test on this
predictor variable was significant at the p < .01 level
(Table 1). However, patients without an E-ED combination j
i
had more shunt problems (t test = p < .05; Table 1). j
The most significant finding regarding the psycho
logical test scores was that the P-F Study scores could
predict total shunt or dietary problems.
i
I
In summary, sexual performance was predictable fromj
separate tests including: (a) the Body Image score, (b) j
the MMPI Ego Strength scale, and (c) the MMPI Factor R
scale. Apparently a high score on Factor R with a subse-
i quent low score on Factor A is important for adjustment to
I home hemodialysis. Patients high on Factor R were able to
reach rehabilitation in sexual potency and employment.
Patients high on Factor R also adhered to diet requirements
and had less excessive laboratory test measures.
The P-F Study was able to differentiate patients
with more shunt problems and with dietary nonadherence.
Patients low in group conformity with an E-ED combination
|had more excess laboratory tests indicative of poor diet
imanagement. Patients with an E direction of aggression who j
'did have an E-ED combination had a higher incidence of
total shunt problems.
Multiple Regression 2. Use of MMPI Scales
j to Predict General Hemodialysis Adaptation
land Rehabilitation Criteria
I ----------------------------
I
Predictor variables. The following 12 MMPI scale
scores were analyzed simultaneously as an intact set in
separate multiple regression analyses to each of the 14
criterion variables. The predictor variables included:
1. MMPI L.
2. MMPI K.
3. MMPI F.
4. MMPI Scale 1 (Hs).
5. MMPI Scale 2 (D).
6. MMPI Scale 3
(Sz).
7. MMPI Scale 4 (Pd).
8. MMPI Scale 5 (Mf).
9. MMPI Scale 6 (Pa).
o
I— I
MMPI Scale 7
(Pt).
11. MMPI Scale 8 (Sc).
12. MMPI Scale 9 (Ma) .
Criterion variables. Criterion variables included
the same set of adaptation and rehabilitation variables
used in the Multiple Regression 1.
A list of the 14 criterion variables is presented
below under the category of results that occurred for the
Iregression analyses:
i
Case 1 (no prediction--low F and low t : tests) .
1. Current level of sexual performance compared to
predialysis level.
2. Satisfaction with current sexual performance.
3. Current happiness compared to people in general.
4. Total chronic medical problems in the past three
months.
5. Total transient symptoms during dialysis.
6. Total transient symptoms following dialysis.
7. Total shunt problems .
Case 2 (partial prediction--high F and low _t tests).
8. Less activity following dialysis.
j Case 3 (partial prediction--low F and high _t tests).
9. Decrease in work hours following dialysis.
10. Total shunt infections in the past three months.
Case 4 (full prediction--high F and high t tests).
11. Differential of marital happiness pre- and post
dialysis .
12. Current hours worked per week.
13. Current happiness compared to other dialysis
. 221 “ j
14. Laboratory tests indicating dietary nonadherence
and dialysis inadequacy.
j
I Discussion of results. None of the MMPI regular
scales were able to differentiate patients on:(a) current
sexual performance, (b) satisfaction over current sexual
iperformance, (c) comparative happiness to people in
general, (d) quantity of chronic medical problems, (e)
transient symptoms during and after dialysis, or (f) total |
shunt problems in the past three months. j
These MMPI scales were able to differentiate j
patients on: (a) less activity following dialysis, (b) j
shunt infections in the past three months, (c) current
i
employment, (d) decrease in work hours, (e) happiness j
compared to other dialysis patients, and (f) laboratory
tests indicating dietary nonadherence and dialysis inade
quacy. The significant _t tests for each of these criterion
variables are presented in Table 2.
: F tests significant at p < .05 or £ < .01, indicat-
j
|ing full prediction, were obtained for: (a) differential
i
of marital happiness, (b) current employment, (c) less
activity following dialysis, (d) happiness compared to
other patients, and (e) dietary nonadherence and dialysis
inadequacy.
j
1. Differential of current marital happiness
compared to predialvsis. Marital happiness remained the
222
TABLE 2
SIGNIFICANT t VALUES ON THE REGRESSION COEFFICIENT
FOR MMPI SCALE PREDICTORS OF GENERAL ADAPTATION
AND REHABILITATION CRITERIA
Criterion Variable Predictor Variable _t Value
Marital Happiness
MMPI Hs
MMPI Pd
MMPI Mf
MMPI Ma
2.03*
2.10*
-2.21*
-3.47*
Current Employment MMPI Pa 2.12*
Decrease work hours MMPI Pd -2.55*
Happiness re patients
MMPI Hs
MMPI D
MMPI Hy
MMPI Pa
-2.56*
-4.47**
3.70**
-3.19**
Shunt infections MMPI Ma 2.46*
Poor diet-dialysis
MMPI Hs
MMPI Pt
3.61**
-2.86**
t (.05/2;36) = 2.03 *p < .05
t (.01/2;36) » 2.72 **p < .01
: - - 223 |
same for patients high on the MMPI Hs and Pd scales
(t. tests = p < .05; Table 2). Marital happiness remained
|the same for patients low on the Mf scale (t test = p < .05;
iTable 2) and low on the Ma scale (t. test = £ < .01; Table
|2). This would indicate more masculine patients, or
ipatients low in activity level or emotional excitability,
or patients high in somatization and irapulsivity tended to
have as much marital happiness following dialysis.
Conversely, patients who: do not somatize, follow social
convention, have more feminine values, or tend to be over-
active and excitable experienced a decline in marital j
happiness following dialysis.
Since the F test of the multiple regression on this
criterion was significant at the p < .01 level, the full |
prediction of differential of marital happiness following j
dialysis was obtainable from these MMPI scales. These
iscales significantly accounted for the variance among
'patients whose marital happiness remained the same or
j
jdeclined following dialysis.
I
I
2. Current employment was related to a high score
on Pa (t test = p < .01; Table 2). Patients, then, with
pervasive suspiciousness and interpersonal sensitivity
tended to maintain full employment following dialysis.
The F test on the regression analysis was signifi
cant at the p < .01 level which indicates that full
! 224 !
i
prediction of current employment was obtainable from the
'MMPI scales. The Pa score significantly accounted for the
I variance among patients employed full-time, part-time, or
j
|unemployed.
j
3. Decrease in work hours following dialysis was
jrelated to a low score on Pd (t test = p < .05; Table 2).
Patients, then, who are more socially conforming worked
fewer hours following dialysis. Since the F test was not
significant at the p < .05 level, other unknown variables j
may also account for the variance in decrease in work hours j
following dialysis. ;
i
4. Less activity following dialysis. The predic- j
tors together accounted for the variance of this criterion
variable (F test = p < .05). However, none of the t tests
were significant at the p < .05 level. This indicates that
jthe MMPI scales accounted for activity differences but the
i
:scales were too interrelated for this criterion to single
lout individual scales as predictors.
i
5. Current happiness compared to other patients
was related to a high Hy score and to low scores on His, D,
and Pa. The jt tests for D, Hy, and Pa were significant at
the £ < .01 level (Table 2). Therefore, patients who
tended to somatize or patients low in: (a) health worries,
|(b) depression, or (c) suspiciousness rated themselves as
| 225 |
jhappier compared to other dialysis patients.
I j
| The F test on the regression analysis was signifi- ;
; I
leant at the £ < .01 level which indicates that full ■
I I
:prediction of self-happiness compared to other patients was ;
t ;
|obtainable from the MMPI Hs, D, Hy, and Pa scales. However,
Inone of the MMPI scales had any predictive power for happi-
! j
jness compared to people in general.
6. Shunt infections were related to a high score
| I
Ion the Ma scale (t, test = p < .05; Table 2). Patients high ;
i
I in energy and emotional excitability tended to have more
I i
jshunt infections. However, the F test was not significant
|at the p < .05 level. This indicates that other unknown
i I
variables may account for the variance in shunt infections
Iduring the three months preceding this study. The MMPI !
scales were not able to distinguish patients on total shunt I
problems.
7. Laboratory tests indicative of nonadherence to I
I diet and dialysis inadequacy were related to a high score
i !
Ion Hs and to a low score on Pt,. The _t test for Hs, was j
[significant at the p < .01 level while the t, test for Pt
|
jwas significant at the p < .05 level. Therefore, patients
|who worry about their health and bodily functions and
I
jpatients who are decisive and not given to obsessive
jcompulsive behavior tended to have poorer dietary control
J
jand dialysis inadequacy. These seem like two opposite
groups to predict the same behavior. However, patients j
overly concerned about their health may deny this worry by j
;not following their diet and by not dialyzing properly.
|Nonworrying, decisive, noncompulsive patients may be
|following their natural, easygoing inclination of not
I closely following any regime.
The F test on the regression analysis was signifi
cant at the p < .01 level. This indicates that full
prediction of excessive biochemical laboratory tests
indicative of dietary nonadherence and dialysis inadequacy
i
was obtainable from the MMPI Hs and Ft scales. j
In summary, some MMPI scales did predict aspects of
i
adaptation to home dialysis. Patients high in Hs. had more
excessive laboratory tests indicative of dietary nonadher
ence and dialysis inadequacy, but tended to feel as happily
:married as before dialysis. Patients low on Pt also had
more problems with the diet and with adequacy of dialysis.
; Patients low in Hs., D, and Pa, or patients high in Hv,
i
|tended to view themselves as happier than other patients.
Patients high in Ma had a decrease in marital happiness
following dialysis and more shunt infections. Patients
with a high Pa reached full-time employment rehabilitation.
Patients low in Pd worked fewer hours following dialysis.
L.
227
^ Multiple Regression 3. Use of Selection Criteria ;
I to Predict General Hemodialysis Adaptation
and Rehabilitation Criteria
Predictor variables. The purpose of this set of
regression analyses was to determine how reported nonmedica],
selection criteria relate to adaptation. The following 20
I
|items were analyzed simultaneously as an intact set on
separate multiple regression analyses to each of the 18
criterion variables. !
1. Sex.
2. Years of schooling.
3. Distance from home to treatment center.
4. Expectation of transplant.
5. Number of children living at home.
6. Years of marriage.
j 7. Patient rating of emotional support from the
family.
8. Current combined annual income.
9. Proportion of patients' annual dialysis costs
i
to annual income.
10. Worry over finances.
11. Staff rating of cooperation with medical
requirements and in working for his own
successful treatment.
12. Staff rating of emotional adjustment to living
as an artificial kidney patient.
' ~~ ~ 228 1
I
I
13. Staff rating of motivation to be productive ;
|
member of the community. I
| 1
| 14. Staff rating of more dependent and reluctant
to do things for himself than others.
15. Staff rating of more independent and resentful
or resistant to reasonable assistance than
others.
I 16. WAIS Full Scale score.
j
17. Patient Mechanical Comprehension score.
18. Combined operator Mechanical Comprehension
score.
19. Over 45 years of age. I
i
20. Staff rating of emotional support from the
family.
Criterion variables. Criterion variables included
adaptation and rehabilitation factors and MMPI additional
|scales. A list of the 18 criterion variables is presented
below under the category of results that occurred for the
regression analyses.
Case 1 (no prediction--low F and j: tests).
1. Total chronic medical symptoms in the past three
months.
2. Total transient symptoms during dialysis.
3. Total transient symptoms following dialysis.
4. Laboratory tests indicating dietary nonadherence
and dialysis inadequacy.
5. Total shunt problems in the past three months.
6. Less activity following dialysis.
7. MMPI Depression scale.
8. MMPI Factor A scale.
9. MMPI Ego Strength scale.
Case 3 (partial prediction--low F and t tests).
i
10. Differential of marital happiness pre- and post
dialysis .
11. Current level of sexual performance compared to
predialysis level.
12. Decrease in work hours following dialysis.
13. Current happiness compared to people in general.
14. Current happiness compared to other dialysis
patients.
15. Total shunt infections in the past three months.
Case 4 (full prediction--high F and high j: tests).
16. Current hours worked per week.
17. Satisfaction with current sexual performance.
18. MMPI Factor R scale.
Discussion of results. Nonmedical selection
criteria frequently used in the past include: sex, age
under 45 years, education, number of dependents, cost of
dialysis, emotional support, intelligence, or staff ratings
: " 230 j
of adjustment. None of these predictors were able to
differentiate patients on: (a) total chronic medical
problems, (b) transient symptoms during and after dialysis,
(c) shunt problems, (d) dietary nonadherence or dialysis
inadequacy, (e) less activity following dialysis, (f)
depression, (g) ego strength, or (h) worry over health.
i
[
These predictors were able to differentiate
patients on: (a) marital happiness, (b) ratings of self
happiness, (c) sexual performance, (d) sexual satisfaction,
i
(e) current employment, (f) decrease in work hours, and
(g) shunt infections in the past three months. The signif
icant jt tests for each of these criterion variables are i
presented in Table 3.
Significant F tests indicating full prediction were
obtained for: (a) current employment, (b) sexual perform
ance and satisfaction, and (c) the MMPI Factor R scale.
i 1. Differential of marital happiness pre- and
]
postdialvsis was separately related to sex, cost of
dialysis, and financial worry (t_ tests = p < .01; Table 3).
Males had less decrease in marital happiness following
dialysis than females. No decrease in marital happiness
was also related to dialysis costing a higher percentage of
combined annual income and to nonworry over finances.
Since the F test was not significant at the p < .05 level,
other unknown variables may also account for the variance
TABLE 3
SIGNIFICANT t VALUES ON THE REGRESSION COEFFICIENT
FOR SELECTION CRITERION VARIABLES TO GENERAL
ADAPTATION AND REHABILITATION CRITERIA
Criterion Variable Predictor Variable t. Value
Marital happiness
Sex
Cost of dialysis
Financial worry
-3.01**
3.09**
-3.43**
General happiness
Emotional support
Intelligence
2.22*
2.33*
Happiness re patients Overdependency 2.96**
Sexual performance
Sex
Years of school
j .
j ' j '
0 0 00
C M CM
Sexual satisfaction
Emotional support
Cost of dialysis
-2.50*
3.20**
Employment
Rating of productivity
Combined Mechanical
Sex
Children at home
2.78**
-2.39*
2.19*
-2.05*
Decrease work hours
Children at home
Over 45 years
Distance from center
2.42*
2.32*
-2.24*
Shunt infections Overdependency 2.96**
Poor diet-dialysis Income 2.20*
MMPI Factor R
Emotional adjustment
Years of marriage
2.28*
2.14*
t (.05/2;36) - 2.03
t (.01/2;36) = 2.72
*£ < .05
**£ < .01
in marital happiness following dialysis.
; !
2. Happiness compared to people in general was !
related to higher intelligence and to the patient's higher
rating of emotional support received from the family
(t. tests = p < .05; Table 3). Since the F test was not
significant at the £ < .05 level, other unknown variables
'may account for subjective ratings of general happiness.
3. Happiness compared to other dialysis patients
i
was related to a staff rating of the patient being more j
dependent than average (t test = p < .01; Table 3). More j
i
dependent patients may receive more attention or favored ;
handling from the family and staff which makes them feel
happier. Or their feelings of happiness may be based on
denial necessitated by the dependent stance. To admit
unhappiness would require more self-responsibility in the
|control of one's destiny. Since the F test was not signif-
i
iicant at the p < .05 level, other unknown variables may
I
account for feelings of happiness in comparison to other
patients.
4. Sexual performance was related to years of
school and to sex. Females had fewer problems with
decrease in sexual performance (t: test = p < .05; Table 3).
Patients with more education had fewer problems with
impotency or decreased sexual performance (jt test =» p < .05;
Table 3) which may be due to greater knowledge of sexual
233 !
i
function and to the psychological factors involved. Since
.the F test was not significant, other unknown variables may
i
account for sexual performance following dialysis.
5. Satisfaction over sexual performance was
related to lower patient ratings of family emotional
support and to higher costs of dialysis (_t tests => p < .05
land p < .01, respectively; Table 3). Patients with less
emotional support may have a poorer marital relationship
and thereby may be less concerned about their sexual |
performance. The relationship between cost of dialysis and
satisfaction over sexual performance was obscure. Perhaps j
j
in cases where dialysis is a great financial hardship, the
patient must justify the value of dialysis and thereby
tends to deny and repress depression and dissatisfaction in
I all areas of less adequate functioning following dialysis.
|Since the F test was significant at the p < .01 level,
|these variables sufficiently accounted for the variance of
I
satisfaction over sexual performance for patients on home
dialysis.
6. Employment was related to staff ratings of
motivation to be a productive member of the community
(t. test = p < .01; Table 3). Greater employment was also
found among: (a) females, (b) patients with fewer children
at home, and (c) patients with a low combined operators'
Mechanical Comprehension score (_t tests = p < .05; Table 3).
The staff ratings which were current would be expected to !
; |
jcorrelate with employment rehabilitation. It has been said j
that patients with children at home are more motivated to
rehabilitate occupationally, but this was not found in this
sample. On the contrary, patients in this sample with
small children worked fewer hours. Interestingly, women
Iworked to fuller capacity following dialysis than men. The
patients' Mechanical Comprehension score was negatively
correlated to the combined operators' score. Therefore,
more compulsive and detailed patients may tend to become
occupationally rehabilitated. The F test was significant
at the p < .05 level which indicates that these variables j
|
sufficiently accounted for the variance of hours per week
employment for these patients.
7. Decrease in work hours was related to the
inumber of children at home, age over 45 years, and to the
distance of the home from the treatment center (t_ tests =
£ < .05; Table 3). Patients with dependents and patients
over 45 years of age tended to work fewer hours following
dialysis. Since females resumed fuller employment capacity,
male fathers tended to show a decrease in work hours
following dialysis. This finding is opposite to the report
of Meldrum et al. (1968).
It has been said that self-sufficiency increases
with the distance from the treatment center. This study
235 I
j confirmed this finding since patients who lived further j
;away from the treatment center had less decrease in work
hours following dialysis. Since the F test was not signif
icant, other unknown variables may account for the variance
among patients in decrease in work hours following dialysis.
| 8. Shunt infections were related to a high staff
!rating of being more dependent than the average patients
(t_ test = p < .01; Table 3). More dependent patients would
tend to be less responsible for cannula self-care which may
increase the probability of infection. Since the F test
was not significant, other unknown variables may account
for the variance among number of shunt infections in the
! i
preceding three-month period.
9. Laboratory tests indicative of dietary non-
!adherence and dialysis inadequacy were related to combined
.annual income (jt test =» p < .05; Table 3). Wealthier
i
patients tended to be less cooperative in following their
diet. Perhaps patients with higher incomes are used to
more independence in decision making and have more diffi
culty in taking orders from the medical staff regarding
their food intake. Since the F test was not significant,
other unknown variables may account for the variance in
dietary adherence.
! 10. MMPI Factor R was related to staff ratings of
the patient's emotional adjustment and to years of marriage
! (t. tests = p < .05; Table 3). The staff rating, then,
; supports the conclusion that good adjustment to the
stresses and demands of dialysis involves much utilization
of the defense mechanisms of denial and rationalization.
Apparently patients married longer have higher scores on
I Factor R. It would be an interesting speculation to con-
| elude that to maintain a lasting marriage requires the
| development of denial and rationalization to minimize
I
! dissatisfaction with the partner and the marital position.
| In summary, it appears that nonmedical selection
j
criteria were generally not useful in predicting adaptation
or rehabilitation success on home dialysis. If adaptation
is defined as a lessened incidence of: shunt or dietary
control problems, chronic medical complications, and
; transient symptoms during and after dialysis, then none of
the usual nonmedical selection criteria appear to have any
predictive power for adaptation to dialysis. A 45-year
i cutoff, age, sex, intelligence, education, dependents,
i cooperation, or cost of dialysis had no relationship to the
; above adaptation criteria.
I
Emotional support and intelligence appeared to
I relate to feelings of well-being but not to the usual
i
! adjustment or rehabilitation criteria. The nonmedical
selection criteria had no relationship to the patients1
feelings of anxiety, depression, or ego strength following ;
dialysis.
These nonmedical selection criteria had a minimum
relationship to rehabilitation criteria. Females tend to
have higher employment and sexual functioning rehabilita
tion than males. Male patients with more dependents tended;
to have the least employment rehabilitation. This would
weaken the claim that males with small children are more
motivated to work. |
Shaldon (1968) stated that Mechanical Comprehension!
was the most important factor in rehabilitation. No !
i
evidence was found for this in this study. Mechanical I
Comprehension either in terms of the patient's score or the!
combined operators' averaged score had no relationship to
rehabilitation or adaptation criteria. There is slight
possibility that the Mechanical Comprehension score of the
dialysis operator is negatively related to employment. |
However, not all patients operate their dialysis equipment.!
Therefore, the negative relationship of the operator's
mechanical score to patient employment is not clearly
defined nor supported by this study.
n ~ ~ 238
I
!
i Multiple Regression 4. Dialysis and Medical
!
; Factors Relating to Job Rehabilitation
and General Activity
Predictor variables. The purpose of this set of
I regression analyses was to examine how treatment, dialysis,
! and medical factors relate to employment and activity
! j
i rehabilitation. The following 18 items were analyzed
I simultaneously as an intact set on separate multiple
I |
j regression analyses for each of the four criterion vari-
i
j
| ables.
|
1. Age.
2. Months between diagnosed kidney disease and
| symptom onset. I
3. Months between symptom onset and first i
|
| dialysis. j
j ]
4. Number of weeks of home training. j
j ;
5. Total training hours. j
6. Months on home dialysis.
I
I 7. Hours per week of home dialysis.
i
8. Number of dialyses per week.
9. Day vs. night dialysis schedule.
10. Primary responsibility for operating dialysis.
11. Sleep during dialysis.
12. Hours per week in equipment maintenance.
13. Location of shunt.
14. Predialysis serum creatinine.
239 !
15. Current neuropathy compared to neuropathy
when began dialysis.
16. Diagnosed myocardial failure, congestive heart
failure, or pulmonary edema. j
17. Total chronic medical complications in the
past three months.
18. Parallel-plate vs. coil dialyzer.
i
Criterion variables. Criteria of job and activity !
rehabilitation are presented below under the category of
i
results that occurred for the regression analysis: j
j i
Case 1 (no prediction--low F and low j t tests).
! 1. Change in occupation following dialysis. j
| ]
! 2. Less activity following dialysis.
Case 3 (partial prediction--low F and high _t tests).
3. Decrease in work hours following dialysis.
Case 4 (full prediction--high F and high jt tests). |
; 4. Current hours worked per week.
Discussion of results. None of the dialysis- i
I related and medical predictors were able to differentiate
;patients on change of occupation or less activity following!
i :
!dialysis.
: i
j Predictors in this subset were able to differen- I
i |
tiate patients on current employment and decrease in work i
! 240 i
f •
I hours following dialysis. The significant t_ tests for
! these criterion variables are presented in Table 4.
j A significant F test indicating full prediction
i was obtained for current employment. |
1. Current employment was related to months
between symptoms and first dialysis, and to age (t, tests =
ip < .05 and p < .01, respectively; Table 4). Younger ■
patients worked more hours per week. Patients with a
j
I slower developing case of renal failure who had a longer
j time span between symptoms and first dialysis worked at
i :
| fuller employment capacity following dialysis. This may
| indicate that patients with slower developing renal failure^
I had a better chance to accept their condition and make
adaptations to their life. Since the F test was signifi- ;
; cant at the p < .05 level, full prediction for the variance
in employment was obtained from these variables.
2. Decrease in work hours following dialysis was
related to total number of training hours and to weeks of
I training (jt tests » p < .01 and p < .05, respectively;
I Table 4). Patients with fewer weeks of training worked
fewer hours per week following dialysis. Also patients
I with an excessive amount of training hours, who may be slow
1 !
| learners or have complications preventing release to a home|
program, tended to be employed less than before home |
dialysis. These two predictors may appear contradictory
TABLE 4
SIGNIFICANT t VALUES ON THE REGRESSION COEFFICIENT
FOR DIALYSIS AND MEDICAL VARIABLES TO EMPLOYMENT
AND ACTIVITY REHABILITATION CRITERIA
Criterion Variable Predictor Variable t, Value
Current employment
Age
Symptoms to first dialysis
-2.71*
2.58*
Decrease work hours
Weeks of training
Total training hours
-2.56*
3.30**
t (.05/2;36) = 2.03 *£ < .05
t (.01/2;36)
i
i
i
|
- 2.72 **p < .01
! unless decrease in work hours following dialysis is related1
to both extremities of training. Patients, then, with both
i minimal and excessive training tended to not regain
; predialysis employment levels. Since the F test was not
significant, other unknown variables may account for
decrease in employment following dialysis.
i
In summary, none of the illness-related variables,
I or variations in dialysis procedure related to job
rehabilitation. The dialysis schedule in terms of fre-
j quency or length of run had no relationship to employment
rehabilitation. Patients who dialyze at night instead of
; during the day did not work to a fuller capacity. Shunt
location, current neuropathy, or total chronic medical
complications had no relationship to job rehabilitation.
The predialysis serum creatinine indicating level of uremia
has no relationship to resumption of employment even though
it would seem likely that patients placed on dialysis with
i severe uremia would tend to have more medical complications:
preventing employment resumption. The choice of a coil or ;
; parallel-plate dialyzer had no relationship to job ;
I rehabilitation. It has been stated that patients with j
coronary problems are less able to work, but this was not |
; found to be the case in this study.
Months on home dialysis has no relationship to j
employment resumption. Therefore, some patients resume |
! i
r 243 !
I I
I work immediately. Furthermore, patients who work fewer
I hours in the early months of home dialysis tended to work
I ;
I fewer hours at a later date.
Although age is related to current employment, it
is not related to decrease in work hours following
dialysis. Therefore, the oldest patients tended to be less
employed following dialysis but they were also less
i employed before dialysis. It appears apparent that job
| rehabilitation should be broadened to include both current ;
i ;
; employment and decrease in work hours following dialysis to!
I i
| gain an accurate assessment of job rehabilitation. If
j |
! current employment is used as the sole criterion of job
!
rehabilitation, as is currently the case, a distortion i
I arises in terms of attainment of predialysis capacity. j
i |
j Multiple Regression 5 . Dialysis. Medical ,
I and Personal Factors Relating j
i to Sexual Performance
Predictor variables. Since impotency is a common j
:problem with dialysis patients, the purpose of this set of
i regression analyses was to examine factors relating to
I
i sexual performance rehabilitation. The following 25
I personal, medical, and dialysis-related items were analyzed
; i
!simultaneously as an intact set on separate multiple
|regression analyses for each of the three criterion vari- j
I
!ables.
244 I
I
1. Sex. j
j
2. Age. ■
j
3. Years of schooling. j
4. Months on home dialysis.
I
5 . Hours per -week of home dialysis. i
6. Number of dialyses per week.
7. Current urine quantity in a 24-hour period.
8. Years of marriage.
9. Differential of marital happiness pre- and
j
postdialysis. j
10. Patient's rating of emotional support from
j
the family. I
i
11. Current combined annual income. I
j
12. Worry over finances.
13. Sexual attractiveness of the patient to the ;
spouse.
14. Impotence discussed with the patient by the
staff.
15. Patient told by the staff that impotence or ,
decreased sexual activity is a common occur
rence with dialysis patients.
16. Serum creatinine before first dialysis.
|
17. Current neuropathy compared to neuropathy when j
began dialysis. !
18. Total chronic medical problems in the past j
three months.
' 245 ]
1 19. Both kidneys removed.
| i
i 20. Body Image score.
! 21. WAIS Full Scale score. ;
i 22. Parallel-plate vs. coil dialyzer. j
! i
23. Total transient symptoms following dialysis.
[ '
j 24. Laboratory tests indicating dietary nonadher-
j !
I ence and dialysis inadequacy.
I ' i
| 25. Total shunt problems in the past three months.j
I
| :
| Criterion variables. Criteria of sexual rehabili
tation are presented below under the category of results
that occurred for the regression analysis:
Case 3 (partial prediction--low F and high t : tests).
1. Current level of sexual performance compared to
I predialysis level.
i ;
| 2. Satisfaction with current sexual performance.
3. Months of impotence.
Discussion of results. These predictor variables
I were able to differentiate patients on all three criteria, j
j The significant t_ tests for each criterion are presented
i !
in Table 5. None of the F tests were significant at the |
n < .05 level which indicates that other unknown variables
! i
imay account for the variance in these criteria.
i j
| 1. Sexual performance was related to a decrease in|
| marital happiness following dialysis (t. test = p < .05; j
246 !
!
i
I
TABLE 5
I
SIGNIFICANT t VALUES ON THE REGRESSION COEFFICIENT FOR
DIALYSIS, PERSONAL, AND MEDICAL FACTOR VARIABLES !
TO SEXUAL PERFORMANCE CRITERIA
Criterion Variable Predictor Variable jt Value
Sexual performance Marital happiness -2.24*
Sexual satisfaction Sex 3.05**
Months of impotence
Hours per week dialysis
Current neuropathy
Emotional support
2.76**
2.85**
2.61*
t (.05/2;36) = 2.03 *£ < .05
t (.01/2; 36) = 2.72 **£ < .01
jT a b le 5). P a t i e n t s w h o s e s e x u a l p e r fo r m a n c e r e m a in e d t h e |
[same a s b e f o r e d i a l y s i s t e n d e d t o b e l e s s h a p p i l y m a r r ie d
f o l l o w i n g d i a l y s i s . I m p o te n t p a t i e n t s o r p a t i e n t s w i t h j
m a r k e d d e c l i n e i n s e x u a l a b i l i t y f o l l o w i n g d i a l y s i s h a d no
I d e c r e a s e i n m a r i t a l h a p p i n e s s . T h is may i n d i c a t e d e n i a l
f u n c t i o n i n g i n p a t i e n t s w i t h a l o s s o f s e x u a l a b i l i t y . |
i i
: !
: I
2. Sexual satisfaction regardless of actual
performance was related to sex (t: test = p < .01; Table 5). |
jF em a les w e r e m o re s a t i s f i e d w i t h t h e i r s e x u a l a b i l i t y . T h e ;
|
Multiple Regression 3 results indicated that females also
i ■ ;
I !
h a d l e s s d e c r e a s e i n s e x u a l a b i l i t y f o l l o w i n g d i a l y s i s t h a n i
I |
i
m a l e s .
j ;
3. M o n th s o f im p o t e n c e w a s s e p a r a t e l y r e l a t e d t o
] :
h o u r s p e r w e e k o f d i a l y s i s a n d t o c u r r e n t n e u r o p a t h y
i
( t t e s t s = £ < .01; T a b le 5). M o n th s o f im p o t e n c y w as a l s o
r e l a t e d t o t h e p a t i e n t ' s r a t i n g s o f e m o t i o n a l s u p p o r t
(t t e s t = £ < .05; T a b le 5). I m p o te n t p a t i e n t s h a d f e w e r [
p r o b le m s w i t h n e u r o p a t h y a n d t e n d e d t o d i a l y z e m o re h o u r s
p e r w e e k . T h ey h a d a h i g h e r r a t i n g f o r e m o t i o n a l s u p p o r t
jfrom t h e i r s p o u s e .
| A p p a r e n t ly g o o d d i a l y s i s m a n a g em en t i n te r m s o f |
[ t o t a l h o u r s p e r w e e k o f d i a l y s i s h a d n o r e l a t i o n s h i p t o :
I i
physical well-being evidenced in job or sexual performance
rehabilitation (see Multiple Regression 4). Neuropathy did
| i
h o t d e c r e a s e s e x u a l p e r f o r m a n c e i n s e x u a l l y f u n c t i o n i n g
^patients. Conversely, lack of neuropathy does not relate
I
|to sexual rehabilitation.
In summary, sexual performance was not related to
aspects of the patient's current medical condition or
:dialysis regime. Differences in treatment or physical
| health had no bearing on sexual performance following
I dialysis for patients in this study. Impotent patients had;
|less neuropathy and more hours of dialysis per week than
i :
patients whose sexual performance remained the same follow
ing dialysis. The severity of uremia before beginning
j
| dialysis or current residual kidney function has no bearing
i
Ion sexual performance. Intelligence, education, age, 1
! I
financial worries, or bodily satisfaction also had no
|relationship to sexual functioning following dialysis.
It then appears that sexual performance following !
dialysis had no relationship to physical factors. Rather,
sexual functioning following dialysis appears to be prima
rily related to subtle, complex psychological factors !
including marital dynamics.
249
Multiple Regression 6. Dialysis. Medical,
|and Personal Factors Relating to Shunt
j and Dietary Adherence Problems
^ Predictor variables. Cooperation with the hemo-
i dialysis regime has been previously defined as the ability
I
| to adhere to the diet and to properly care for the shunt.
j
! Cooperation thus defined would mean a lessened incidence of
| shunt problems and of laboratory test results indicating
i
dietary nonadherence or dialysis inadequacy. The purpose
of this set of regression analyses was to uncover factors
| relating to shunt, diet, and dialysis problems. The
i
j following 28 items were analyzed simultaneously as an
| intact set on separate multiple regression analyses for
I each of the 16 criterion variables:
1. Age.
2. Sex.
3. Use of blood pump during dialysis.
I
4. Months between symptom onset and first
| dialysis.
; 5. Number of weeks of home training.
j j
6. Total training hours.
7. Months on home dialysis.
i
8. Hours per week of home dialysis.
9. Number of dialyses per week.
10. Primary responsibility for dialysis operation.
250 j
i
11. Greater bleeding problem following dialysis
|
not attributable to heparin or coumadin.
12. Patient's rating of emotional support from thei
j
family.
I
13. Location of shunt.
14. Shunt on preferred arm.
15. Patient's self-confidence about handling the j
j
dialysis. j
16. Patient's confidence about the helper. i
17. Helper's self-confidence about handling the j
dialysis.
18. Staff rating of patient cooperation.
19. Staff rating of emotional support from the :
family.
20. Serum creatinine before first dialysis.
21. WAIS Full Scale score.
i
22. Patient Mechanical Comprehension score.
23. Combined operator Mechanical Comprehension
averaged score.
24. P-F Study Group Conformity Rating. j
25. P-F Study E-I-M.
26. P-F Study E-ED combination vs. other.
i
27. Parallel-plate vs. coil dialyzer.
28. On home dialysis over one year.
251 1
i
Criterion variables. Criterion variables of shunt ;
and dietary problems and of dialysis inadequacy are
presented below under the category of results that occurred:
for the regression analyses:
Case 1 (no prediction--low F and t tests) . |
1. Number of surgical repairs of venous line in past
three months. j
2. Number of shunt infections in past three months. j
I
3. Frequent weight loss greater than 1 kilogram j
dur ing dialy s is.
4. Serum potassium greater than 6.5 in the past three !
months.
5. BUN greater than 90.0 in the past three months.
6. Predialysis uric acid greater than 9.0 in the past j
three months.
7. Total laboratory tests indicating dietary non
adherence or dialysis inadequacy in the past three
months.
Case 3 (partial prediction--low F and high t tests).
8. Number of times patient declotted shunt in the j
past three months. I
9. Number of hospital declots in the past three
months.
10. Number of surgical repairs of arterial line in the
past three months.
~ ' ~~ ’ ~ ‘ _ ~ 252
| 11. Range of weight loss during dialysis in the past j
j 1
three months. i
: i
12. Average weight loss during dialysis in the past
three months.
13. Serum albumin below 3.5 exclusive of illness or !
infection in the past three months.
! 14. Serum creatinine greater than 16.0 in the past j
I
i i
| three months.
I
i 15. Predialysis phosphate greater than 10.0 in the |
|
| past three months.
i !
| 16. Total shunt problems in the past three months. j
i
| i
Discussion of results. These predictors were able ;
! to differentiate patients on some of the specific shunt
j problems and some laboratory tests indicative of dietary
nonadherence and dialysis inadequacy. The significant J:
tests for each criterion are presented in Table 6. None of:
the F tests on the regression analyses for each criterion
were significant at the p < .05 level which indicates that
i other unknown variables may account for the variance in
these criteria.
i
| 1. Number of times the patient declotted his shunti
I
j ]
I in the past three months was related to intelligence and
! the combined Mechanical Comprehension score (_t tests = ;
i i
] I
jp < .05; Table 6). More intelligent patients and patients j
j — i
jwith lower combined operator mechanical aptitude scores had!
253
TABLE 6
j
SIGNIFICANT t VALUES
DIALYSIS, MEDICAL,
RELATING TO SHUNT
ON THE REGRESSION COEFFICIENT FOR
AND PERSONAL FACTOR VARIABLES
AND DIETARY CONTROL CRITERIA
Criterion Variable Predictor Variable _t Value
Patient declots
WAIS Full Scale score
Combined Mechanical
2.65*
-2.07* :
Shunt clots
Weeks of training
Total training hours
Number dialyses per week
Dialysis operator
Predialysis creatinine
Confidence re helper
Type of dialyzer
WAIS Full Scale score
Combined Mechanical
-2.05* |
3.19**
-3.17**
-2.10* i
2.24* !
-2.76**
3.43** ;
2.26*
-2.13* ;
Arterial repairs
Shunt location
Combined Mechanical
3.52** 1
2.46*
Total shunt problems
Weeks of training
Type of dialyzer
WAIS Full Scale score
P-F E-I-M
-2.31* 1
2.79**
3.11**
-2.76** ;
Range weight loss Shunt on preferred arm -2.59* :
Average weight loss Hours per week dialysis 2.82** :
Serum albumin < 3.5
Shunt location
Age
2.04*
2.23* :
Serum creatinine > 16.0 Predialysis creatinine 2.51*
Phosphate > 10.0
Total training hours
Hours per week dialysis
Number dialyses per week
Patient self-confidence
2.17* !
-3.22** i
2.27* |
-2.22* |
Uric acid > 9.0 Patient self-confidence 2.07* I
t.( .05/2; 36) = 2.03 *p < .05
t(.01/2;36) =2.72 **p < .01
1 254 |
j j
! more self-declotting of shunts. j
2. Total shunt declots in the past three months
were separately related with Jt tests = £ < .05 level
: (Table 6) to: (a) fewer weeks of training; (b) another
person, not the patient, operating the dialysis procedure;
! (c) higher intelligence; (d) lower combined operator
: mechanical aptitude; and (e) higher predialysis serum
t j
j creatinine. Total shunt declots were also separately
| related with J: tests = £ < .01 level (Table 6) to: (a)
i excess training hours; (b) fewer dialyses per week; (c) use!
| of parallel-plate dialyzer; and (d) lower patient ratings
I
i regarding their confidence about the helper's ability to
i j
| handle the dialysis. |
3. Total shunt problems in the past three months
: including infections, clots, and repairs were separately
related to: (a) higher intelligence; (b) use of parallel- I
plate dialyzer, and (c) behavioral style of externalizing
aggression to frustration (t. tests = £ < .01; Table 6).
I Total shunt problems were also related to minimal weeks of i
| training before beginning home dialysis (_t test = p < .05; i
i Table 6). Patients with higher intelligence may also learnj
! faster and be sent home faster. j
i
I i
; i
4. Repairs of arterial cannula line in the past j
i
three months were separately related to a higher combined
! 255 !
( i
| operator mechanical aptitude and to shunt location in the j
: arm (t. tests = £ < .01 and £ < .05, respectively; Table 6).
I ;
I , i
| 5. Range of weight loss during a single dialysis
I in the past three months. Patients with the shunt not
located in the preferred arm had a higher absolute weight j
loss during a single dialysis run (_t test = £ < .05;
; Table 6). j
I 0. Average weight loss during dialysis in the past;
! three months was related to greater hours of dialysis per
i
week (t. test = £ < .01; Table 6). Since frequency of '
dialysis per week was not related to average weight loss, !
j it appears that patients with excess fluid may dialyze more!
i hours per week to remove this fluid.
j 7. Serum albumin below 3.5 exclusive of illness or
infection during the past three months was separately
;related to shunt located in the arm and to greater age
(jt tests = £ < .05; Table 17). If this test is an indirect!
measure of malnutrition, older people in general tend to
have poorer nutritional habits. No evidence was found for 1
|the occurrence of low serum albumin as a function of I
' |
etiology on prior peritoneal dialysis therapy which lends j
|support to the findings of Bischel, Sabin, Homola, and |
Barbour (1969). j
8. Serum creatinine over 16.0 in the past three
i .
: months was related to a higher predialysis serum creatinine;
| (t test = p < .05; Table 6).
9. Predialvsis phosphate over 10.0 in the past
; three months was separately related to: (a) excess train- i
i ;
! ing hours, (b) fewer hours of dialysis per week, (c) more
I frequent dialyses per week, and (d) lack of self-confidence|
: j
; in the patient about operating the dialysis (t, tests = I
i ;
i £ <
.05, £ < .01, p < .05, and p < .05, respectively;
; Table 6). i
i I
10. Predialvsis uric acid over 9.0 in the past
I three months was related to greater patient self-confidence
I about operating the dialysis (j: test = £ < .05; Table 6).
I .
In summary, these medical, personal, and dialysis- ;
related predictor variables were not able to differentiate !
! i
; patients on: (a) venous repairs, (b) shunt infection, (c) I
excess fluid intake, or (d) BUN and serum potassium labor
atory tests. These predictor variables were able to
■ i
| differentiate patients on: (a) shunt declots, (b) arterial;
; repairs, (c) total shunt problems, (d) range and average !
! i
I !
| weight loss during dialysis, and (e) serum albumin, i
I !
predialysis phosphate, predialysis uric acid, and serum j
! |
| creatinine laboratory tests. I
2 5 7 -1
Shunt clotting problems were related to psycholog
ical as well as dialysis-related and medical factors.
IPatients who directed their aggression to frustration
externally and who projected hostility had more shunt
clotting problems. I
Patients with either an excess or minimal amount of
‘ training before beginning home dialysis had more clotting
‘ problems. Also a low combined mechanical aptitude was
related to higher incidence of shunt clots. Patients with
inadequate training or training difficulties or patients
i I
[with poor mechanical aptitude may not handle the dialysis
[procedure optimally which results in clotting problems.
| Self-responsibility for dialysis appears important
ifor minimizing shunt clotting problems. Patients had more
Ishunt clots who: (a) were dialyzed by someone else, (b) had
!a lower confidence about the helper's ability to run the
[dialysis procedure, and (c) had fewer dialyses per week.
Patients with higher intelligence tended to have ,
more clots and to do their own declotting than patients ;
with lower intelligence. The only medical differentiation
■was that patients with greater uremia before beginning the
I 1
jinitial dialysis with a higher predialysis serum creatinine j
had more shunt clots. j
| Shunt problems may be related to the shunt location !
! i
I !
|or to the type of dialyzer. Patients with an arm shunt had J
more arterial cannula repairs. Patients with a parallel-
' plate dialyzer had more shunt clots and total shunt
| problems. Shunt location had no bearing on venous cannula
repairs. The use of a blood pump was not related to shunt
i problems.
Patients with more hours of dialysis per week
tended to lose more body weight on each run. It appears
that patients with excess fluid intake dialyzed more hours
! per week in the process of ultrafiltration or in excess
I fluid removal.
i
| Regarding laboratory test measures indicative of
malnutrition and of dialysis inadequacy, low serum albumin
| was more frequent in older patients and patients with an
i arm shunt. Patients with higher predialysis serum
creatinine before initial hospital dialysis tended to have
i
serum creatinines over 16.0 following home dialysis.
: Patients highly confident about their ability to operate
: the dialysis tended to have higher predialysis uric acid
measures over 9.0 following home dialysis. Patients with
excessive or minimal training and patients with more
I frequent dialyses per week but fewer total hours of
j dialysis per week had a greater frequency of predialysis
j phosphate over 10.0. More hours of dialysis per week might
lessen the incidence of the phosphate measure over 10.0.
| Multiple Regression 7. Dialysis and Medical
: Factors Relating to Transient Symptoms i
during and after Dialysis
; i
Predictor variables. The purpose of this set of
l regression analyses was to discover physical bases for
transient symptoms during and after dialysis that are
experienced by many patients. The following 28 items were
analyzed simultaneously as an intact set on separate j
j multiple regression analyses for each of the 23 criteria
variables.
1. Sex.
2. Age.
3. Use of blood pump during dialysis.
4. Weeks of home training.
5. Total number of training hours.
6 . Months on home dialysis.
7. Hours per week of home dialysis.
8. Number of dialyses per week.
9. Day vs. night dialysis schedule.
10. Primary responsibility for dialysis operation.
11. Sleep during dialysis.
12. Responsibility for equipment maintenance.
13. Hours per week in maintenance of equipment.
14. Current urine quantity in 24-hour period.
15 . Location of shunt.
16. Shunt on preferred arm.
r 26o1
I ;
I j
j 17. Patient's self-confidence about handling the
i '
j dialysis.
| 18. Patient's confidence about the helper. j
19. Average weight loss during dialysis in the j
i l
past three months.
I 20. Range of weight loss during dialysis in the
| |
| past three months.
| 21. Helper's self-confidence about handling the
I \
dialysis.
22. Hypertension during dialysis in the past
three months.
i 23. Hypotension during dialysis in the past three j
j i
! months.
! I
| 24. Both kidneys removed.
* 25. WAIS Full Scale score. ;
i
26. Patient Mechanical Comprehension score.
; 27. Combined operator Mechanical Comprehension I
averaged score.
! 28. Parallel-plate vs. coil dialyzer. i
I ■ !
| Criterion variables. Criterion variables of j
j transient symptoms during dialysis and on the day following!
|
j dialysis are presented below under the category of results
j
j that occurred for the regression analyses:
Case 1 (no prediction--low F and low t. tests).
1. Leg muscle cramps during dialysis.
2. Irritability during dialysis.
3. Irregular heartbeat during dialysis.
4. Nervousness following dialysis.
5. Headache following dialysis.
6. Leg muscle cramps following dialysis.
7. Nausea following dialysis.
8. Vomiting following dialysis.
9. Total transient symptoms following dialysis.
Case 3 (partial prediction--low F and high j t tests)
10. Nausea during dialysis.
11. Vomiting during dialysis.
12. Headache during dialysis.
13. Sleepiness during dialysis.
14. Restlessness during dialysis.
15. Total transient symptoms during dialysis.
16. Listlessness following dialysis.
17. Irritability following dialysis.
18. Depression following dialysis.
19. Sleepiness following dialysis.
20. Restlessness following dialysis.
21. Low blood pressure following dialysis.
22. Dizziness following dialysis.
f “ ” ' ~ ~ ~ ~ ~ 262 " 1
Case 4 (full prediction--high F and high _t tests) .
23. Dizziness during dialysis.
i
Discussion of results. The dialysis related or
medical variables in this predictor subset were not able to
j differentiate patients on the following transient symptoms I
: during dialysis: (a) leg muscle cramps, (b) irritability,
or (c) irregular heartbeat. These predictors were not able
;to differentiate patients on the following transient symp-
!toms experienced on the day after dialysis: (a) nervous -
|ness, (b) headache, (c) leg muscle cramps, (d) nausea,
(e) vomiting, or (f) total transient symptoms.
These predictors were able to differentiate
i ;
patients on the following transient symptoms experienced i
during dialysis: (a) nausea, (b) vomiting, (c) headache,
(d) sleepiness, (e) restlessness, and (f) total number of
transient symptoms. These predictors were also able to
differentiate patients on the following transient symptoms
experienced on the day following dialysis: (a) listless
ness, (b) irritability, (c) depression, (d) sleepiness,
;(e) restlessness, (f) low blood pressure, and (g) dizziness.
i !
The significant t tests for each of these criteria vari- j
; |
ables are presented in Table 7 for during dialysis vari
ables and in Table 8 for day after dialysis variables. |
j j
| The only significant F test, indicating full j
i |
prediction, was obtained for dizziness during dialysis.
263
TABLE 7
SIGNIFICANT t VALUES ON THE REGRESSION COEFFICIENT
FOR DIALYSIS-RELATED AND MEDICAL PREDICTORS TO
TRANSIENT SYMPTOMS DURING DIALYSIS CRITERIA
| Criterion
I Variable
Predictor Variable t Value
Nausea
; Vomiting
I Headache
Dizziness
I Sleepiness
I
|Restlessness
iTotal symptoms
Day vs. night schedule
Number dialyses per week
Total training hours
Day vs. night schedule
Age
Use of blood pump
Total training hours
Hours per week dialysis
Number dialyses per week
Day vs. night schedule
Primary operator
Maintenance responsibility
Shunt location
Shunt on preferred arm
Patient self-confidence
Confidence re helper
Helper self-confidence
Hypertension during dialysis
Hypotension during dialysis
Both kidneys removed
WAIS Full Scale score
Hours per week maintenance
Both kidneys removed
Day vs. night schedule
2.07*
2.03* |
2.54* !
-2.99** |
-2.98** !
-2.58* :
-3.82** :
-2.41* !
3.80**
4.54**
-3.21** i
3.57**
-2.41*
-2.50*
-3.16** ;
2.53*
-3.62**
4.63**
4.42**
3.32** j
3.85** :
2.17* !
2 . 22*
I
2.32* !
t (.05/2;36) - 2.03
t (.01/2;36) - 2.72
*p < .05
'*p < .01
264 !
TABLE 8
SIGNIFICANT t VALUES ON THE REGRESSION COEFFICIENT FOR
DIALYSIS-RELATED AND MEDICAL PREDICTORS TO TRANSIENT
SYMPTOMS ON THE DAY FOLLOWING DIALYSIS
Criterion Variable Predictor Variable t Value
Listlessness
Sex
Number dialysis per week
-2.22*
-2.75**
Irritability Sex -2.15*
Depression
Sex
Type of dialyzer
-2.37*
2.67*
Restlessness Both kidneys removed 2.13*
Sleepiness Day vs. night schedule 2.66*
Low blood pressure
Months on home dialysis
Number dialyses per week
Primary operator
Sleep during dialysis
Responsibility maintenance
Urine quantity
Hypotension during dialysis
2.35*
-2.81**
2.25*
2.15*
-3.36**
-2.28*
-2.82**
Dizziness
Day vs. night schedule
Helper self-confidence
Hypertension during dialysis
2.45*
-2.60*
2.37*
t (.05/2;36) = 2.03 *p < .05
t (.01/2;36) =2.72 **p < .01
1. Nausea during dialysis was related to time of
day of dialysis. Patients who dialyzed primarily at night
had more nausea during dialysis (t. test = p < .05; Table 7).
2. Vomiting during dialysis was related to
frequency of dialysis. Patients with a greater number of
dialyses per week had more vomiting during dialysis
(t_ test * p < .05; Table 7).
3. Headache during dialysis was related to total
training hours and to time of day of dialysis. Patients
with an excess of training hours and patients who dialyze
primarily during the day had more headaches during dialysis
(t. tests = p < .05 and p < .01, respectively; Table 7).
4. Sleepiness during dialysis was related to totali
hours per week spent in cleaning and repairing the equip
ment (_t test = p < .05; Table 7). Patients with excess
hours of cleaning equipment may have less time to rest or
sleep and therefore may be sleepier during dialysis.
5. Restlessness during dialysis was related to
having both kidneys removed ( j : test = p < .05; Table 7). |
6. Dizziness during dialysis was independently
related to many variables whose t. tests at p < .05 and |
|
£ < .01 are presented in Table 7.
266 j
I |
In terms of personal characteristics, more
dizziness during dialysis is experienced by patients who :
: separately are: (a) younger, (b) higher in intelligence,
(c) have someone else operate the dialysis but who
i
primarily clean the equipment themselves, (d) have no self-j
confidence in their ability to handle the dialysis, (e)
have high confidence about their helper's ability, or ;
(f) have helpers with low self-confidence about their
j |
jability to handle the dialysis. j
I In terms of the dialysis procedure, more dizziness
| during dialysis was experienced by patients who separately:
!(a) had a minimum of training hours, (b) did not use a
blood pump, (c) had more dialyses per week but fewer total
hours of dialysis per week, (d) dialyzed primarily at
!night, (e) had the shunt located in the leg, or (f) had an
arm shunt in the nonpreferred arm.
In terms of medical factors, more dizziness during
dialysis was experienced by patients with either hyperten- ;
sion or hypotension during dialysis, or by patients with
both kidneys removed. Since the F test was significant at
! the jd < .05 level, the above variables account for the |
I |
variance among patients regarding dizziness during dialysisJ
; |
! !
7. Total transient symptoms during dialysis was !
i j
related to time of day of dialysis. Patients who dialyzed
primarily at night experienced more symptoms during
| dialysis (jt test ** p < .05; Table 7).
8. Listlessness following dialysis was related to
| sex and frequency of dialysis (t. tests = p < .05 and
£ < .01, respectively; Table 8). Males and patients with
fewer dialyses per week had more listlessness on the day
| after dialysis.
I
9. Irritability following dialysis was related to
sex (t test = p < .05; Table 8). Males felt more irritable
on the day following dialysis
j
10. Depression following dialysis was related to
i
I sex and to type of dialyzer (t. tests = p < .05; Table 8).
I Males and patients with a parallel-plate dialyzer had more
i depression on the day after dialysis.
11. Restlessness following dialysis was related to
having both kidneys removed ( j : test = p < .05; Table 8).
12. Sleepiness following dialysis was related to
i time of day of dialysis. Patients who primarily dialyzed
at night were sleepier on the day following dialysis
j
; (t_ test => p < .05; Table 8). The fact that patients in
i this study generally did not sleep during dialysis could
! account for a portion of this finding, except that the
1
; sleep during dialysis predictor had no relationship to
J
| sleepiness following dialysis.
I ~ " " 268
i j
13. Dizziness following dialysis was separately j
related to: time of day of dialysis, the helper's self-
confidence about handling the dialysis, and hypertension
; during dialysis (t tests = p < .05; Table 8). Patients
who: (a) primarily dialyze at night, (b) have hypertension;
during dialysis, or (c) have no confidence in the helper
: experienced more dizziness on the day following dialysis.
J i
14. Low blood pressure following dialysis was
! i
| related to various dialyses and medical factors. The _t
i '
|tests for these factors at p < .05 or p < .01 are presented
'in Table 8.
In terms of the dialysis procedure, a higher inci
dence of low blood pressure on the day following dialysis
jwas experienced by: (a) patients who dialyzed fewer times
per week, (b) patients who operated the dialysis procedure
themselves, (c) patients who slept during dialysis, or (d)
patients who left the maintenance and cleaning of the
dialysis equipment to another family member.
In terms of medical factors, more low blood pres
sure on the day following dialysis occurred for: patients
with less residual kidney function who had the least urine
j output per day or patients who do not experience hypoten-
jsion during dialysis.
I i
I j
| In summary, symptoms during and after dialysis were
differentially related to medical, dialysis procedural, and
! psychological factors. The time of day of dialysis was
; related to some transient symptoms. Patients who dialyzed
: at night had more nausea, dizziness, and total symptoms
; during dialysis. They also experienced more sleepiness and
dizziness on the day following dialysis. Patients who
; dialyzed during the day had more headaches during dialysis.
Frequency of dialysis related to symptoms.
| Patients with more frequent dialyses per week had more
| vomiting and dizziness during dialysis. Patients with
j i
ifewer dialyses per week had more listlessness and low blood
! pressure on the day following dialysis. I
! Dizziness during dialysis was also separately
j related to: (a) minimal training hours, (b) fewer hours
per week of dialysis, (c) the dialysis operated by someone
;other than the patient, and (d) lack of confidence in both
the patient and the helper about running the dialysis
procedure. Some of the experienced dizziness during
dialysis may be due to technical factors involving subopti- |
^ i
mum operation of the dialysis.
Medical factors also determined experienced dizzi-
|ness during dialysis. Patients with both kidneys removed j
|or patients with hypotension during dialysis had more
i j
|dizziness during and after dialysis.
Patients with both kidneys removed experienced more j
irestlessness during and after dialysis. j
Males experienced more listlessness, irritability, j
j or depression on the day following dialysis than females.
! This would indicate that males are more affected psycholog-:
! ically in a negative manner by dialysis and have more
: difficulty in regaining their psychological equilibrium
; following dialysis.
i ;
Patients on home dialysis a longer time have more
; low blood pressure on the day following dialysis. Also,
; more low blood pressure following dialysis was experienced
i by: (a) patients with fewer dialyses per week, (b)
|
: patients with less residual kidney function, and (c)
patients without hypotension during dialysis.
| With the exception that patients with fewer total
hours per week experienced more dizziness during dialysis,
hours per week of dialysis had no bearing on transient
symptoms during or after dialysis. The amount of weight
; loss during dialysis had no relationship to experienced
transient symptoms during or after dialysis. It was
expected that patients with more ultrafiltration or weight
I loss during dialysis would experience more transient
symptoms. But this was not the case. Intelligence had no
; relationship to experienced symptoms except that patients
i ;
I with higher intelligence had more dizziness during
|dialysis. '
i The choice of parallel-plate or coil dialyzer generf
I ally had no relationship to transient symptoms during or I
; i
I after dialysis. However, patients with a parallel-plate j
dialyzer experienced more depression on the day following
dialysis. Mechanical aptitude was not related to transient
symptoms during or following dialysis.
I
i Multinle Regression 8. Dialysis and
Medical Factors Relating to Chronic
Medical Complications
i
Predictor variables. It has been stated that rapid
i
placement on dialysis for patients with renal failure
before the uremia becomes severe and before medical compli
cations become entrenched lessens the occurrence of chronic
medical complications following dialysis. Also, optimum
!
Sdialysis management should lessen or reverse many chronic
i
imedical complications. The purpose of this set of regres
sion analyses was to determine how medical and dialysis
iprocedural factors related to chronic medical complications
j
The following 28 items were analyzed simultaneously as an
|intact set on separate multiple regression analyses to each
!of the 25 criterion variables:
1. Age.
2. Sex.
3. Distance from home to treatment center.
4. Use of blood pump during dialysis.
' 5. Months between diagnosed kidney disease and
symptom onset.
272 I
6. Months between symptoms and first hospital j
dialysis. !
7. Number of peritoneal dialyses. i
8. Weeks between first peritoneal dialysis and |
first hemodialysis. j
I
9. Hours per week of hospital hemodialysis.
10. Weeks of hospital hemodialysis before beginning !
home training. j
11. Number of weeks of home training.
12. Total training hours.
13. Months on home dialysis.
14. Hours per week of home dialysis. j
15. Number of dialyses per week. I
16. Primary responsibility for dialysis operation, j
17. Sleep during dialysis. i
18. Current urine quantity in a 24-hour period. |
19. Months under 800 cc. urine output per 24-hour i
period. j
20. Range of weight loss during dialysis in the
past three months. j
21. Average weight loss during dialysis in the past
three months.
22. Acquired vs. congenital basis of renal disease. I
23. Serum creatinine before first dialysis.
24. Both kidneys removed.
25. WAIS Full Scale score.
. . _ 273 I
1
i
26. Parallel-plate coil dialyzer. j
27. P-F Study E-I-M.
I
28. Over 45 years of age.
|
Criterion variables. Criterion variables of chronic
medical complications experienced during the three months
j
preceding this study are presented below under the category '
of results that occurred for the regression analyses:
Case 1 (no prediction--low F and low t. tests) . j
1. Trouble sleeping. j
2. Occurrence of tingling or numbness in the hands or
feet.
3. Days of hospitalization in the past three months, j
4. Hypertension during dialysis. j
i
5. Hypotension during dialysis.
6. Diagnosed motor peripheral neuropathy.
7. Diagnosed impotence .
8. Diagnosed hypertension requiring medication.
9. Diagnosed gastrointestinal bleeding. I
Case 3 (partial prediction--low F and high t tests).
10. Regular medication for nerves or sleep.
11. Greater bleeding problems not attributable to
heparin or coumadin.
12. Patient experienced "burning feet" syndrome.
13. Patient experienced uncontrollable restlessness, !
agitation, or twitching of legs.
14. Patient experienced muscle weakness or paralysis
in feet or legs. j
i
15. Patient experienced intense itching skin. ;
16. Diagnosed pruritis. |
17. Current neuropathy compared to neuropathy when
entered dialysis.
18. Diagnosed sensory peripheral neuropathy. ;
19. Diagnosed sepsis.
20. Diagnosed myocardial failure, congestive heart ‘
failure, or pulmonary edema. |
21. Total diagnosed chronic medical complications. |
22. WAIS organic brain damage pattern.
23. WAIS impairment of immediate memory.
Discussion of results. None of the dialysis-related
or medical predictors were able to differentiate patients
on: (a) trouble sleeping, (b) tingling or numbness in the
hands or feet, (c) hypotension or hypertension during ;
j
dialysis, (d) days of hospitalization, or (e) diagnosed
impotence, gastrointestinal bleeding, motor peripheral i
neuropathy, or hypertension requiring medication. |
These predictors were able to differentiate patients
on: (a) patient experienced greater bleeding problems, j
restlessness, muscle weakness, and itching skin, (b)
. .. . _ - 275
|medication for nerves or sleep, (c) diagnosed current •
I neuropathy and sensory peripheral neuropathy, (d) diagnosed
i
! [
jpruritis, renal osteodystrophy, sepsis, and myocardial
1 failure or pulmonary edema or congestive heart failure, (e) ;
total diagnosed chronic medical symptoms, and (f) the WAIS ;
organic brain damage pattern and deficient immediate
memory. The significant t. tests for each of these crite- j
jrion variables are presented in Table 9. ;
| None of the F tests on the regression analyses for
ieach criterion variable was significant at the p < .05
|level. Therefore, other unknown variables may account for
the differentiation among patients in each of the chronic j
jmedical symptoms examined.
1. Regular medication for nerves or sleep was
related to an absence or lessened frequency of peritoneal !
dialyses (t, test = p < .01; Table 9). It also related to:
(a) number of weeks between the first peritoneal dialysis
i ;
land first hemodialysis, (b) weeks of home training, (c) I
i j
months under 800 cc. urine output in a 24-hour period, and
! I
I (d) the WAIS Full Scale score (j: tests = £ < .05; Table 9). j
jPatients with higher intelligence or fewer weeks of train- ;
|ing before beginning home dialysis took more medication for I
I j
jnerves and sleep. Patients with a greater time length
jbetween the first peritoneal and first hemodialysis and j
patients with more months under 800 cc. urine output per j
276 !
i
TABLE 9 !
SIGNIFICANT t VALUES ON THE REGRESSION COEFFICIENT
FOR DIALYSIS AND MEDICAL PREDICTORS TO CHRONIC
MEDICAL COMPLICATION CRITERIA
Criterion Variable Predictor Variable t : Value
i
Nerve or sleep Rx
Number peritoneal dialyses
Weeks from peritoneal to
hemodialysis
Weeks home training
Months under 800 cc. urine
WAIS Full Scale score
-3.65**
2.38*
-2.05*
2.53*
2.71*
Greater bleeding Blood pump -2.21*
Burning feet
Sex
Primary operator
-2.79**
-2.12*
Restlessness
Distance from hospital
Symptoms to first dialysis
Number peritoneal dialyses
Weeks home training
Primary operator
Months home dialysis
Predialysis creatinine
2.44*
2.25*
-2.83**
-3.37**
-2.49*
2.03*
2.66*
Muscle weakness
Blood pump
Type dialyzer
-2.89**
2.65*
Itching skin
Illness to symptom onset
Weeks training
Hours per week dialysis
Frequency dialysis
Sleep during dialysis
Type dialyzer
3.30**
-4.57**
2.54*
-2.64*
-3.79**
2.35*
Current neuropathy
Weeks before training
Months home dialysis
Primary operator
2.22*
-2.63*
2.28*
Sensory neuropathy Distance from hospital -2.13*
277
TABLE 9--continued
Criterion Variable Predictor Variable t, Value
Renal osteodystrophy
Age
Over 45 years
Predialysis creatinine
2.15*
-2.19*
2.60*
Pruritis
Sex
Distance from hospital
Months home dialysis
-2.29*
-2.26*
2.16*
Sepsis
Sleep during dialysis
Urine quantity
Predialysis creatinine
-2.13*
-2.47*
-2.50*
Myocardial failure,
congestive heart
failure, or pulmonary
edema
Blood pump -2.03*
Total chronic symptoms
Distance from hospital
Sex
Hours per week dialysis
P-F E-I-M
-2.56*
-2.05*
-2.07*
-2.38*
WAIS organic
Months under 800 cc.
urine
2.11*
WAIS digit span loss Blood pump 2.03*
t (.05/2;36) = 2.03 *p < .05
t (.01/2;36) = 2.72 **£ < .01
day also had a higher frequency of nerve or sleep medica-
|tion.
2. Patient1s experienced greater bleeding problems
! ;
jnot attributable to coumadin or heparin was related to
iabsence of use of a blood pump (t. test = p < .05; Table 9).
I I
3. Patient* s experienced current severity of burn-
!ing feet was separately related to sex and responsibility
i
|for operating the dialysis (t. tests = p < .01 and £ < .05, i
i |
respectively; Table 9). Males and patients who have another
family member or nurse operate the dialysis procedure
:experienced more problems with burning feet.
| |
j ;
j 4. Patient* s experienced current severity of
^ restlessness was related at the p < .01 level (Table 9) to:
absence or lessened incidence of peritoneal dialyses and to i
fewer weeks of training before beginning home dialysis.
Restlessness was separately related at the p < .05 level
; (Table 9) to: (a) greater distance between home and treat- |
Iment center, (b) greater time interval between symptom
onset and first dialysis, (c) months of home dialysis, (d)
jhigher predialysis serum creatinine before initial hospital |
idialysis, and (e) having another family member or nurse j
[operate the dialysis procedure. !
' i
; !
! 5. Patient * s experienced severity of muscle |
I i
j weakness was separately related to the blood pump and type
|of dialyzer (t tests = £ < .01 and £ < .05, respectively;
jTable 9). Patients who did not use a blood pump and
patients with a parallel-plate dialyzer had more experienced
muscle weakness. j
j ■
6. Patient1s experienced severity of itching skin :
was separately related to: (a) months between diagnosed
|illness and symptom onset, (b) fewer weeks of training
Ibefore beginning home dialysis, and (c) nonsleep during the
Idialysis procedure (t: tests = p < .01; Table 9). Severity
j
|of itching skin was also related to more hours per week of
dialysis but fewer dialyses per week and to the use of a
i ;
jparallel-plate dialyzer (t tests = p < .05; Table 9).
j i
7. Diagnosed severity of current neuropathy was
separately related to: (a) more weeks of hospital dialysis
ibefore beginning home training, (b) fewer months on home
!
idialysis, and (c) patient responsibility for operating the
dialysis (t tests = p < .05; Table 9).
8. Diagnosed sensory peripheral neuropathy was
! I
irelated to less distance between the patient's residence !
Sand the treatment hospital (t: test = p < .05; Table 9).
i 9. Diagnosed renal osteodystrophy was separately
; i
related to (a) age, (b) over 45 years cutoff, and (c) j
Ipredialysis serum creatinine (t. tests = p < .05; Table 9). j
i
Although patients under 45 years of age also have renal____ j
280 j
1
i ;
osteodystrophy, it was most prevalent in the oldest
! ;
patients in this study. Severity of uremia prior to
i !
idialysis was also related to renal osteodystrophy following j
idialysis. j
10. Diagnosed pruritis was separately related to:
| (a) sex, (b) distance from the treatment center, and (c) :
jmonths of home dialysis (t_ tests = p < .05; Table 9).
iMales, patients living closer to the treatment hospital and
J
patients on home dialysis a longer time had more diagnosed j
I !
jpruritis.
I :
j i
; 11. Diagnosed sepsis was separately related to:
i !
(a) predialysis serum creatinine, (b) urine quantity, and
i ;
|(c) sleep during dialysis (t. tests = p < .05; Table 9).
:Patients below an 800 cc. urine output per day, patients
with less severity of uremia prior to dialysis, and
patients who do not sleep during dialysis had more diagnosed
sepsis.
12. Diagnosed myocardial failure, pulmonary edema. i
l or congestive heart failure. Patients who do not use a
i ;
j !
iblood pump during dialysis had a higher incidence of these
jheart complications (t_ test = p < .05; Table 9).
13. Total diagnosed chronic medical symptoms was
|separately related to: (a) distance from the treatment
i
center, (b) sex, (c) hours per week of dialysis, and (d)
281
jdirection of aggression to frustration (t, tests => p < .05;
Table 9). Patients who live closer to the treatment center,
jmales, and patients who dialyze fewer hours per week had
more chronic medical complications. Also, patients who
direct aggression to frustration externally by projecting
hostility and blaming others or outer objects had a higher
incidence of total chronic medical complications.
: j
i !
14. WAIS organic pattern was related to months j
| !
under 800 cc. urine output per day (t: test = p < .05; i
Table 9).
| I
| 15. WAIS digit span deficiency was related to use
;of a blood pump during dialysis (t test = p < .05; Table 9).
| In summary, brain organicity appears to be related
to length of time of loss of residual kidney function while
deficiency in immediate memory was related to the use of a
! !
blood pimp during dialysis. The quality of dialysis manage-!
j j
ment in terms of dialysis, frequency, or total hours per j
week had no bearing on brain organicity. Predialysis j
factors also had no bearing on organic brain damage j
findings.
Males experienced more severity of: burning feet,
!
pruritis, and total diagnosed medical complications.
: I
Patients who did not use a blood pump had more bleeding i
\ i
problems, muscle weakness, and heart complications. !
| 282 |
| Patients with a parallel-plate dialyzer had more severity
[in muscle weakness and itching skin than patients with a
coil dialyzer. Patients in advanced years and patients
with greater severity of uremia before the initial hospital
idialysis had more renal osteodystrophy. Patients on home
dialysis a shorter time had more diagnosed neuropathy.
Patients who lived closer to the treatment hospital
[had more diagnosed pruritis, sensory peripheral neuropathy,
! * I
|and total chronic medical complications. Patients living
[further from the treatment hospital had more experienced
[restlessness.
j ;
j Experienced restlessness was also related to
|severity of uremia before initial hospital dialysis, early
! !
jmanagement factors, and length of time on home dialysis.
[Patients who experienced greater restlessness had: a higher
predialysis serum creatinine, a greater time interval
between symptom onset and first hospital dialysis, and fewer
weeks of training before beginning home dialysis. They do
not operate the dialysis process at home. Perhaps restless-!
ness could be reduced through faster placement on dialysis
[following renal failure and by improved operation of the j
•dialysis process. [
| i
Patient experienced itching skin was related to j
[home dialysis schedule. Patients with: (a) fewer weeks of |
I
training, (b) a parallel-plate dialyzer, (c) more hours per
]
week of dialysis but fewer dialyses per week, and (d) no j
! 283
I
|sleep during dialysis had more severity of itching skin.
I Increasing the frequency of dialysis may decrease the
incidence of itching skin.
| Diagnosed sepsis was related to more severe uremia
prior to onset of dialysis and to reduced residual kidney
[function of urine output -under 800 cc. per day. Patients
iwith sepsis tended to sleep less during dialysis.
More total chronic medical complications were found
among males, patients with fewer hours per week of dialysis,
1
jand in patients who externalize and project hostility to
jfrustration. Quantity of medical complications, then, have
ja psychological basis as well as physical. Perhaps increas
ing the total hours of dialysis per week may lessen the
iincidence of some chronic medical complications. |
! |
Multiple Regression 9. Treatment Hospital
S and Machine Factors Relating to Transient
S and Chronic Medical Complications I
!
Predictor variables. The purpose of this set of
regression analyses was to examine for differences in
jtreatment center or machine manufacturer as affecting j
[transient and chronic medical complications. The following :
i J
jnine items were analyzed simultaneously as an intact set on ;
iseparate multiple regression analyses for each of the 35 j
i j
jcriterion variables: j
1. Cedars-Sinai Medical Center vs. other.
! 2. Veterans Administration Hospital vs. other.
; 3. LAC-USC Medical Center vs. other.
i
| 4. Harbor General Hospital vs. other.
[
| 5. Pasadena Community Hospital vs. other.
I
! 6. MAKS 900 machine vs. other.
|
; 7. MAKS 990 machine vs. other.
8. Drake Willock machine vs. other.
9. Milton Roy machine vs. other.
i
Criterion variables. Criterion variables included:
(a) transient symptoms during dialysis and in the 24 hours
following dialysis, (b) chronic medical complications, (c)
!total shunt problems in the past three months, and (d)
I total dietary problems in the past three months. These
! criteria are presented below under the category of results
that occurred for the regression analyses:
i
Case 1 (no prediction--low F and low t : tests).
| Transient symptoms during dialysis:
I
1. Nausea.
| 2. Vomiting.
| 3. Leg muscle cramps.
4. Headache.
5. Dizziness.
6. Sleepiness.
________7. Restlessness.____________________________________
285 |
j
8. Irritability. j
j
9. Irregular heartbeat. j
10. Total transient symptoms during dialysis. j
i
!
Transient symptoms following dialysis : j
i
11. Listlessness. j
!
12. Irritability.
I
i
13. Nervousness.
14. Depression.
15. Headache.
16. Leg muscle cramps. j
i
17. Sleepiness. !
I
18. Nausea.
19. Vomiting.
20. Restlessness. j
i
21. Low blood pressure. j
22. Dizziness. !
!
23. Total transient symptoms following dialysis. !
i
Diagnosed chronic medical complications : j
!
24. Renal osteodystrophy. j
25. Sensory peripheral neuropathy.
26. Motor peripheral neuropathy.
27. Impotence.
28. Hypertension requiring medication.
29. Sepsis.
I 286 ]
I 1
| 30. Myocardial failure, congestive heart failure,
| or pulmonary edema.
| 31. Total laboratory tests indicating dietary
nonadherence and dialysis inadequacy in the
past three months. i
i ;
Case 3 (partial prediction--low F and high jb tests).
t
j 32. Total shunt problems.
33. Diagnosed pruritis.
[
I Case 4 (full predict ion--high F and high j: tests). j
34. Diagnosed gastrointestinal bleeding.
! 35. Total chronic medical complications in the
past three months. j
i ■
Discussion of results. No treatment center differ- ;
ences were found for any of the criterion variables.
Although the treatment hospitals differed somewhat in
training techniques and medical management of the patients,
these differences had no effect on experienced transient
symptoms during or following dialyses, or on chronic medical
complications.
i !
No machine manufacturer differences were found for [
i i
I j
iexperienced transient symptoms during or following dialysis.;
| i
IThe machine manufacturer had no differentiation for most j
!
jchronic medical complications. However, machine differences
I !
existed for: (a) diagnosed pruritis, (b) diagnosed
287
jgastro intestinal bleeding, (c) total chronic medical com-
|
jplications, and (d) total shunt problems. The significant
i ;
f tests for these criteria are presented in Table 10.
| Significant F tests indicating full prediction were
;obtained for machine differences relating to diagnosed
gastrointestinal bleeding and to total chronic medical
i ;
problems. I
| 1. Total shunt problems in the past three months.
jPatients using MAKS 900 and MAKS 990 machines had more
total shunt problems (t: tests = £ < .05; Table 10).
j
2. Diagnosed pruritis in the past three months.
Patients using a MAKS 990 machine had a significantly higher!
incidence of pruritis (_t test = p < .05; Table 10). !
i |
! 3. Diagnosed gastrointestinal bleeding in the past !
three months. Patients using a MAKS 900 or MAKS 990
machine had a higher incidence of diagnosed gastrointestinal!
bleeding (jt tests = £ < .01; Table 10). Since the F test
Was significant at the p < .01 level, it appears that the
MAKS machines alone accounted for the variance in pruritis
i ;
among patients. j
i I
| i
! 4. Total chronic medical complications in the past ;
three months was related to use of a MAKS 990 machine
I
j(t test = p < .05; Table 10). Since the F test was signif-
i
leant at the p < .05 level, dialysis procedural factors
288
TABLE 10
SIGNIFICANT t VALUES ON THE REGRESSION COEFFICIENT
FOR HOSPITAL AND MACHINE PREDICTORS TO TRANSIENT
AND CHRONIC MEDICAL COMPLICATION CRITERIA
Criterion Variable
Predictor
Variable
j
t . Value ;
Gastrointestinal bleeding
MAKS 900
MAKS 990
3.62**
3.77**
Pruritis MAKS 990
i
2.11*
Total chronic medical MAKS 990 2.44*
Total shunt problems
MAKS 900
MAKS 990
2.48* :
2.29*
t (.05/2;36) - 2.03 *p < .05
t (.01/2;36) = 2.72 **£ < .01
i
involving the use of the MAKS 990 machine accounted for the
i
|variance in incidence of total chronic medical complica-
Itions among patients.
In summary, no treatment hospital differences
existed for any transient symptoms during and after dialy-
|sis nor for any chronic medical complications. Apparently
|all hospitals in this study have equally effective dialysis
management programs.
No dialysis machine differences existed for transi
ent symptoms during and after dialysis and for most chronic
medical complications. However, patients with a MAKS 900
or MAKS 990 machine had a significantly higher incidence of
|gastrointestinal bleeding or total shunt problems,
i Patients with a MAKS 990 machine also had a significantly
higher incidence of diagnosed pruritis and total chronic
;medical problems. Obviously, further studies should be
undertaken to determine the basis of the MAKS 900 and MAKS
990 inadequacies in treatment management or to determine if
:this result was a sampling effect. It is unlikely, but
jpossible, that all patients with these problems happened
jby chance to use the MAKS machines.
j CHAPTER X
I
S DISCUSSION
i
I A Priori Hypothesis Findings
Medical complications as a function of length of
|time on home dialysis. Generally speaking, patients on
dialysis a longer time did not have more chronic medical
problems than new patients. The long-term patients only
had more incidence of: (a) pruritis, (b) restlessness in
the legs, and (c) low blood pressure following dialysis.
However, they had less current neuropathy than the short-
iterm patients which indicates that neuropathy may be
ireversible through good dialysis management. The long-term
patients were no better or worse than new patients in the
iareas of sexual functioning, job rehabilitation, or cooper
ation with dialysis regime. A significant finding of this
study is that continued long-term hemodialysis does not
^necessarily result in other medical problems.
Transient symptoms during dialysis as a function of
the dialvzer. No supportive evidence was found in this
study for the choice of a parallel-plate dialyzer to mini
mize transient symptoms during dialysis. In this study,
| 291 ]
|patients with a parallel-plate dialyzer did not have less
transient symptoms during or after dialysis. Furthermore,
|patients with a parallel-plate dialyzer had more shunt
clots, total shunt problems, muscle weakness, itching skin,
and depression following dialysis than patients with a coil
|dialyzer. The coil dialyzer was not related to a higher
incidence of any singular transient or chronic medical
i i
t :
I complication.
1
i ;
| Signs of organic brain pathology as a function of
I :
'length of time on home dialysis or elapsed time between
t :
ionset of renal failure and first dialysis. No evidence was :
!
|found for this hypothesis. Severity of renal failure prior
ito first dialysis was not related to current findings of
!organic brain damage. A pattern of organic brain damage
Iwas related to months under 800 cc. urine output per day,
or, in other words, to loss of residual kidney function.
Current dialysis schedule differences in frequency or total :
hours of dialysis per week also had no relationship to ;
organic brain pathology pattern findings. In this study, a;
: j
significant deficiency in immediate memory was related to |
luse of a blood pump during dialysis.
; !
| Validity of an age cutoff selection criterion. |
jPatients over 45 years of age did not have significantly |
worse medical problems than patients tinder 45 years. Very
I
| elderly patients did have more renal osteodystrophy and
I 292
! I
|indications of malnutrition. But they exceeded younger
patients in only these two medical problems. Older
;patients did not have more shunt problems or transient
symptoms during or after dialysis. Furthermore, they had
less dizziness during dialysis than younger patients.
ITherefore, it can be accurately stated that patients over
[45 years of age had as good adaptation to dialysis as
[patients who were younger.
In terms of rehabilitation, older patients attained [
i !
the same levels of general activity and sexual functioning
j j
|as the younger patients. However, they did have more
j :
[difficulties with job rehabilitation. Patients over 45
[years of age had a decrease in work hours following dialy
sis which was not shown for younger patients. Very elderly
patients were most unemployed; but some were also retired.
Minimum intelligence as a requisite for successful
home dialysis adaptation. The 11% of the patients in this
[study who were borderline or dull normal in intelligence
| j
-were not significantly worse than brighter patients in
iterms of medical problems, job or sexual functioning [
rehabilitation, or cooperation with shunt care and manage-
!
ment of the dialysis process. There was slight evidence [
i [
that patients higher in nonverbal intelligence had more [
' j
[decrease in work hours following dialysis and more biochem- i
i ;
jical measures indicative of dialysis inadequacy. However, j
! 293 !
r ‘
|these results did not hold for total intelligence.
Patients with a higher over-all intelligence tended
!to feel happier. But brighter patients also took signifi
cantly more regular medication for nerves and sleep which
indicates that they experienced more anxiety and worry.
Brighter patients also had more dizziness during dialysis.
Generally speaking, rehabilitation and successful
i !
|adaptation to home hemodialysis did not relate directly to j
|functioning intelligence in the patient. No minimum j
|
jintelligence cutoff was found for adaptation success.
j ;
Shunt and dietary problems as a function of direc-
|
I tion of aggression to frustration. A major initial !
| |
jhypothesis of this paper was that patients high on intro-
punitive direction of aggression to frustration would take
i ;
out their aggression on themselves and thereby have a
higher incidence of shunt or dietary problems. The results
of this study contradict this hypothesis.
In effect, patients with high extrapunitive scores
on the P-F Study who projected blame and anger to others ;
had more shunt infections, total shunt problems, and total
Ichronic medical complications. Furthermore, patients high
Ion E-ED combination who externalized aggression with the
Ifocus on ego-defensiveness rather than focusing on a solu- |
Ition or the frustrating obstacle had a higher incidence on |
j I
noncooperation with salt and water intake restrictions and
294 !
ia higher incidence of measures indicating dialysis inade-
jquacy. Also, patients with low group conformity on the P-F ;
!Study had significantly greater problems with diet and |
: dialysis management.
The patient who projects hostility to aggression
externally has more cannula, dietary, and dialysis manage-
I |
ment problems. The significance of this finding is that j
|externalizing patients may have excessive, maladaptive
denial in which the illness and its severity is denied.
i
i
This denial and nonacceptance of life as a dialysis patient j
I
blocks cooperation and result in more shunt, dietary, and
| i
[dialysis inadequacy problems.
I i
i !
The relationship of staff attitude towards the
i patient and successful adaptation. Staff ratings of the j
jpatient's personality and behavior had little relationship
I to successful adaptation or rehabilitation. The ratings j
( |
[could not differentiate patients on transient and chronic
medical complications, dietary adherence, or adequacy of |
[dialysis. j
! i
No evidence was found in this study to confirm the j
| ;
jobservation by Norris (1968) that the dependent patient is j
I I
[less likely to look for employment while the overly j
[independent patient who may be a treatment rebel is more |
[likely to maintain his former work patterns. In this study |
| ;
no differences were found among patients rated by the staff j
jas overly dependent, overly independent, or average in
I terms of job rehabilitation or sexual functioning
|rehabilitation. Work rehabilitation was related to staff
rating of motivation to be a productive member of the
i community.
Morris (1968) indicated that the overly dependent
Ipatient may be more cooperative with the treatment regime.
i
jHowever, patients rated as overly dependent in this study
had a significantly higher incidence of shunt infections.
The overly dependent patients in this study appeared to be
less cooperative and less meticulous about cannula care.
I The relationship of emotional support and success
ful adaptation. In selecting patients, emotional support
|from the family is generally considered to assure success-
i
ful adaptation to home dialysis. In this study, amount of
emotional support from the family as rated by the patient
and by staff observation was found to have no relationship
I to successful adaptation or rehabilitation criteria.
i
! f
However, patients rating of emotional support was related
to feeling happy and to satisfaction over current sexual
iperformance. The conclusion from this study is that strong
i
|emotional support from the family does have a positive
I
effect on the patient's psychological well-being. But
jquality of emotional support does not appear related to
Jtangible factors of adaptation and rehabilitation such as
! 296 I
[transient or chronic medical complications, cannula prob
lems, cooperation with dietary and dialysis adequacy
requirements, or current employment.
; i
' Significance of Psychological Defense J
Mechanisms to Adaptation and
i I
Rehabilitation Criteria
j ' ' !
The most significant finding of this study was that ;
successful adaptation to a home dialysis program and
! i
'successful rehabilitation were primarily related to the :
quality of the patient's functioning psychological defense J
mechanisms. As expected, medical and dialysis procedural
'factors did differentially relate to specific problems I
regarding: transient symptoms during dialysis, dialysis
iadequacy, chronic medical complications, and shunt compli- ,
ications. However, the total incidence of problems in any
lone of these areas related primarily to the psychological
state of the patient. Furthermore, dialysis procedural and
medical health factors had little relationship to aspects
of rehabilitation.
i
The results of this study confirmed previous find
ings (Coogan, 1969; McNamara, 1967; Short & Wilson, 1969; j
Wright et al., 1966) that denial is a common, adaptive j
.defense mechanism. High scores on the MMPI Factor R scale, j
j |
jindicating high denial, rationalization, and lack of effec
tive self-insight, was significantly related to better
i
cooperation with diet, adequacy of dialysis, rehabilitation I
297 i
|of sexual function, and staff ratings of emotional adjust- |
[ment. Patients without effective denial who had high
I scores of the alternate MMPI Factor A scale, indicating a
[high degree of felt personal discomfort, distress, anxiety,
i ;
or general emotional upset, had significantly poorer job
! rehabilitation, as measured by both current employment and
[by decrease in work hours following dialysis.
I
| Generally speaking, patients with highly developed !
|denial were significantly more cooperative with dietary and
I j
|dialysis management requirements and had significantly ;
jbetter rehabilitation in the areas of work and sexual
|functioning. Therefore, the use of denial as an adaptive
i
[mechanism not only helps the patient cope with the stresses j
|of dialysis, but helps the patient to cooperate with the
[treatment regime and to carry on his previous life style.
More research is needed with the scales to determine if it
i :
[is the high score on Factor R that differentiates "success- [
ful" patients or the high score on Factor A that differen
tiates "nonsuccessful" patients on specific areas of
adaptation or rehabilitation. |
However, the danger of massive denial is that it
may continue into a delusional process which may explain j
; t
jeating binges (Glassman & Siegel, 1970). Support for this j
statement was found through the P-F Study scores. Patients I
|
high on extrapunitive direction of aggression to frustra- j
i
tion had significantly more problems with diet cooperation i
I 298
r
i
|and dialysis management as well as more chronic medical
j
iproblems. The overly externalizing patient who projects
all hostility denies any personal involvement with his
I problems. He may even deny his illness or its severity
Iwhich blocks cooperation with shunt, dietary, and dialysis
|operation needs.
It appears, then, that high denial is an adaptive
j
|defense mechanism in dialysis patients as long as it does
|not become too massive to prevent his cooperation with
j
treatment needs. The question arises of how denial can be
measured to be certain that it is within an adaptive range
for dialysis patients. This study indicates that the
|combined use of the MMPI Factor R and A scales and the P-F
Study categories may be useful tools in assessing "healthy"
|denial among dialysis patients.
I The Validity of Nonmedical Selection
Criteria Variables to Successful
Adaptation and Rehabilitation
Since current facilities can only accept a small
ipercentage of the medically suitable candidates for hemo-
idialysis, nonmedical selection criteria are used to try to
iassure that the patients selected will successfully adapt
!to the dialysis program and successfully rehabilitate to
; their former life style.
|
| A significant finding of this study was that
frequently used nonmedical selection criteria did not______
I " ’ .’ ....’ ' ”299 1
| j
|differentiate patients on successful adaptation. Further- |
more, the findings of this study indicate that if
‘nonmedical criteria must be used, a new approach in terms
:of assessing the candidate's psychological defense mechan
isms may more validly relate to successful adaptation.
Specifically, in this study such nonmedical selec
tion criteria as: (a) age, (b) sex, (c) education, (d)
number of dependents, (e) income, (f) cost of dialysis,
i(g) emotional support, (h) intelligence, (i) mechanical j
1 :
i :
I aptitude, or (j) staff ratings of adjustment were not able !
!to differentiate patients on: (a) total chronic medical
iproblems, (b) transient symptoms during or after dialysis,
i(c) total shunt problems, (d) dietary noncooperation, or
(e) dialysis inadequacy. These selection criteria also did;
I 1
not differentiate patients on psychological well-being
factors such as: depression, ego strength, or worry over
■health.
Patients over 45 years of age did have a decrease
in work hours following dialysis but they did not have more ;
medical, cannula, dietary, or dialysis adequacy problems.
|Some patients in their fifties and sixties were fully
1 i
|rehabilitated and lacked any complicating disease.
! This study contradicts the findings of Meldrum
j |
|et al. (1968) that younger patients with children are more ;
imotivated to rehabilitate occupationally. In this study, j
patients with small children at home were least employed. I
| 300 I
j
jFemale patients were more employed than males, but this may
jbe an artifact of more stringent selection requirements for
jfemales since male patients outnumbered female patients
2:1.
The results of this study question the validity of
I intelligence as a selection criterion. Intelligence was
inot related to any adaptation or rehabilitation criteria.
A dull normal intelligence has been stated as sufficient as •
jlong as the patient understands the basic mechanisms of his |
jkidneys, the dialyzer, and the demands of the treatment
regime (Cummings, 1970). A borderline defective patient
did as well as brighter patients in this study. This study,
|then, lends support to Cummings' statement. It appears that
|any patient should be accepted to a home dialysis program,
regardless of intelligence, who can sufficiently understand I
what is required.
Family emotional support has been one of the few
generally accepted factors for successful patient adapta- ;
; i
ition. In this study quality of emotional support only j
j :
affected the patient's feeling of well-being. Emotional
support had no relationship to aspects of adaptation or j
^rehabilitation. Pentecost (1970) also found that studying
I i
jthe candidate's family was not successful in predicting the j
ipatient's future dialysis management behavior. !
| It seems likely that a patient with strong emotional
[
support would do better on dialysis; but if this is not j
I 301 !
| i
|supported by factual evidence, it is then imperative that
|patient selection on the basis of subjective assessments of
i :
I
emotional support be halted. Currently the home dialysis
patient population includes few single or divorced adults
Iwho live alone. This indicates that single candidates are
generally rejected. The rejection of candidates on the
|basis of single status appears to be biased, prejudicial,
jand invalid in terms of assuring successful home dialysis
j i
patients. Furthermore, is it appropriate to screen married
patients on the basis of marital harmony and support? Many
marriages successfully survive in which the relationship is ;
ipathological and seemingly destructive, to the observer,
; i
!because it is based on the fulfillment of neurotic, hostile ;
ineeds. Is there any proof that candidates with good ego
j ;
strength but little emotional support in a destructive
: i
marriage would do poorer on dialysis? There is a real need
! j
|for studies to affirm the value of emotional support as a j
nonmedical selection variable to justify its continued use
i :
in choosing candidates.
A weakness of this study's reliability in assessing
nonmedical selection predictors was a post hoc analysis
Susing preselected patients. However, on each of the |
; j
jnonmedical selection predictors a heterogeneous range of
I i
i i
Ipatients was found since the hospitals involved had liberal
nonmedical selection policies.
No evidence was found in this study that the
[ 302 1
I !
! f r e q u e n t l y u s e d n o n m e d ic a l s e l e c t i o n v a r i a b l e s s i g n i f i
c a n t l y d i f f e r e n t i a t e d p a t i e n t s i n a s p e c t s o f a d a p t a t i o n o r
' r e h a b i l i t a t i o n . T h e r e f o r e , a m a jo r i s s u e r a i s e d b y t h i s
j o v e r - a l l s t u d y i s t h e n e e d t o r e - e x a m in e t h e u s e o f
| n o n m e d ic a l s e l e c t i o n c r i t e r i a f o r t h e p r e d i c t i o n o f s u c c e s s ;
; t o a home d i a l y s i s p r o g r a m . F u r t h e r m o r e , p a t i e n t s u c c e s s
! t o a home d i a l y s i s p rog ram i n c l u d e s t h e s e p a r a t e a r e a s o f j
| a d a p t a t i o n , r e h a b i l i t a t i o n , and p s y c h o l o g i c a l a d j u s t m e n t ,
j S u c c e s s f u l a d a p t a t i o n i n v o l v e s a l e s s e n e d i n c i d e n c e o f j
| t r a n s i e n t and c h r o n i c m e d i c a l c o m p l i c a t i o n s , f e w e r s h u n t j
I p r o b l e m s , an d c o o p e r a t i o n w i t h t h e d i e t and d i a l y s i s
i r e q u i r e m e n t s . S u c c e s s f u l r e h a b i l i t a t i o n i n v o l v e s t h e
| r e t u r n t o p r e d i a l y s i s a c t i v i t y l e v e l s i n e m p lo y m e n t, s e x u a l ;
I f u n c t i o n i n g , an d s o c i a l i n v o l v e m e n t . S u c c e s s f u l p s y c h o l o g - |
; i c a l a d j u s t m e n t i n v o l v e s a r e t u r n t o p r e d i a l y s i s e g o
; s t r e n g t h , e m o t i o n a l w e l l - b e i n g , an d minimum p s y c h o l o g i c a l
p r o b le m s a r i s i n g from d i a l y s i s . T h e r e f o r e , i t m u st b e i
d e t e r m in e d i f n o n m e d ic a l s e l e c t i o n c r i t e r i a p r e d i c t s u c c e s s |
! t o a d i a l y s i s p rogram and w h e t h e r t h e y a r e p r e d i c t i n g
s u c c e s s f u l p rogram a d a p t a t i o n , r e h a b i l i t a t i o n , o r p s y c h o - j
I l o g i c a l a d j u s t m e n t .
! j
T h is s t u d y i n d i c a t e s a n e e d f o r f u t u r e r e s e a r c h o n j
I j
| t h e c a n d i d a t e ' s p s y c h o l o g i c a l d e f e n s e s t r u c t u r e a s a m ore
j j
v a l i d n o n m e d ic a l s e l e c t i o n c r i t e r i o n o f s u c c e s s t o a home j
d i a l y s i s p r o g r a m . M ore s p e c i f i c a l l y , c o u l d s c o r e s on t h e j
MMPI F a c t o r A an d F a c t o r R s c a l e s and s c o r e s on t h e j
Picture-Frustration Study predict which candidates will
t :
have the most successful adaptation, rehabilitation and !
mental health following home dialysis? The results of this I
study indicate that these test scores may be able to make
these predictions. |
I ;
I Comments on Sexual Functioning
! i
I The majority of the patients on home dialysis have
|sexual difficulties following dialysis. Impotence occurred-
j ;
;in 30% of all the patients, or 43% of the males. Some were
i
jimpotent before renal failure. Another 41% of the patients i
lhad a decrease in sexual activity following dialysis.
|Approximately 75% of the patients then had sexual problems.
An accurate assessment of sexual difficulties among i
jfemale patients may be difficult to obtain. Physicians are ;
! reluctant to initiate a conversation on this topic with
i :
;female patients. Furthermore, the female patient may
return to predialysis sexual activity which involves
chronic frigidity. i
A significant finding was that psychological
dynamics primarily account for the differences in sexuality :
among dialysis patients. Patients with good sexual func- I
jtioning were patients with a high degree of denial and
t I
^rationalization. They would tend to ignore anxiety,
i . |
jdepression, or physical pain that could affect a more j
jsensitive person's sexual behavior.
304 |
The usual reasons advanced for sexual decline among
i 1
idialysis patients or people in general were not found to be
'operating in the patients in this study. Advanced age,
■ length of time on home dialysis, residual kidney function,
current health, or quantity of depression had no relation
ship to sexual performance. Some patients in their fifties
were sexually active while patients in their twenties were
iimpotent. Some new patients beginning home dialysis were
sexually active while some of the patients longest on j
dialysis in better health were impotent. Physical health |
I !
jhad no relationship to sexual functioning ability. In fact I
jimpotent patients had less neuropathy and more hours of
| ;
! dialysis per week. Strongly depressed patients could
iperform sexually. Therefore, strong depression or poor
physical health can reduce sexual activity but not exclude
it. i
The importance of denial in dialysis patients was
verified by ratings of satisfaction with current perform-
jance which had little correlation to actual functioning
lability. Although 71% of the patients had sexual difficul- i
ties, 73% were satisfied with their sex life. The implica- |
ition of this finding is that the staff may be treating
ipatient sexuality as more of a problem area than the j
Ipatient. Since denial is adaptive for successful adjustment
i
to dialysis, perhaps sexual difficulties should be ignored
305 |
unless it is causing great mental discomfort to the patient I
I
or family strife.
j
I Implications for Healthy Spouse Adjustment
' Little of the family pathology reported in the
literature was found. However, most spouses strongly
resented a shift in family roles involving more responsi- i
Ibility in work or decision making. Amount of unhappiness
i
tabout the role shift was directly proportional to the
I !
I !
!increase in responsibility. Spouses also resented dialysis
| j
!implications. Spouses stated that they were unhappy over a
|more responsive family role when, in fact, there was no
j
|change nor added responsibility to their family role.
Spouses strongly missed giving up outside social activities :
such as piano lessons, women's clubs, drinking with buddies,;
'etc. They especially missed contact with their friends.
Rawnsley (1970b) stated that some wives cope with
the strain of dialysis by seeking employment outside of the ;
ihome because this gives them an outside interest. The
jmajority of the spouses in this study, or 77%, are employed.
Many wives with preschool children work. It appears that
jmost spouses feel guilty about abandoning the patient by
imaintaining their previous recreational pursuits outside the
jhome. Work supplies needed psychological distance from
■dialysis, and they can rationalize the justification for
: i
employment on economic reasons.
t ;
' It is tragic that spouses do not understand that
|their needs to maintain outside recreational activities are
ivalid and necessary to their emotional health. Resentments,
disappointments, and futility feelings develop in the
spouses in proportion to the constriction of their previous
jactivities. For good family adjustment to dialysis, it is
i ;
vitally important that the spouses and children maintain
their previous life style as much as possible. They must
Icontinue to enjoy their hobbies and social activities.
i j
! Families need to be helped to accept their recreational
I !
jneeds without guilt feelings.
! The patient can survive quite well if left alone
jfor a few hours. On the dialysis night, if someone must be ;
present, it would be sensible to hire a sitter rather than
have a resentful, captive spouse. However, some patients
in this study successfully dialyze with no one present in
the home. By not involving their families in dialysis,
their spouses were free of the usual resentments. Their
marriages appeared to be exceptionally happy.
!
: The Need for Psychic Distance: Job j
^ Rehabilitation Implications
There is no question that patients and their
jfamilies who pursue outside interests have the best
emotional adjustment following dialysis. There is a healthy
need for periodic psychic and physical distance from any |
| 307
i
|problem, stress, or worry. The personal value of work and
I recreation lies in the opportunity to become absorbed in an
|activity which distracts self-preoccupation and excessive
'introspection. This distancing from personal concerns
;recharges the emotional and intellectual apparatus to more
!effectively and objectively deal with personal problems.
|The dialysis patient, more than any other chronically ill
jperson, has more constant and continued reminders of his
!ill health in his ever-present shunt, dietary restrictions,
!
land frequent dialyses.
| Too many dialysis patients in this study were
|completely absorbed in their bodily states and the dialysis
I
jmachine. These patients were generally unemployed. It is
important for the dialysis patient to return to work as
rapidly as possible before destructive self-preoccupation
becomes entrenched. Work gives the patient psychic
; distance from his dialysis role as well as raising his
morale and self-esteem and supplying purposefulness to his
-life. Self-preoccupied patients must be helped to attain
Aperiodic psychic distance from dialysis even if this
; entails an enforced weekly evening out to a suspenseful
1
jraovie.
| 308 !
j 1
i The Dialysis Machine as an Entity |
Other authors have found pathological unconscious
! fantasies in the dialysis patient in which the patient
incorporates the machine into his body image, views himself;
as a zombie or android, or experiences an umbilical fantasy
: to the machine (Abram, 1969a; Abram, 1969b; Shambaugh
j et al., 1967; Wright et al., 1966). These unconscious
| fantasies were not found in the patients in this study.
| However, a different fantasy process was observed
i in some patients in which the machine was viewed as a
j personified entity. The machine was treated as another
! member of the family. These patients would insist upon
: showing the Investigator the machine shortly upon arrival.
I They would then proudly describe the machine's attributes.
1 I
i This display of the machine had the flavor of an introduc
tion to the mother-in-law who remains in the background
; during the visit. Patients who treated their machines as
entities were markedly ego-constricted and generally j
unemployed with limited interests beyond their physical
state or the dialysis process.
; For some patients the machine physically dominates
j the home. Dialysis apparatus is everywhere and patients ■
even make love next to the machine in their bedroom. To
i i
! avoid letting the machine dominate the family setting, it j
|would be best to dialyze in a separate room or to store thej
| j
jmachine out of sight in a closet when not in use. It is j
! 309 !
I ;
:important for the patient and his family to not overiden
tify with dialysis. They must first see themselves as any ;
;other family and only secondly as a family in which one
: member has a chronic medical problem. Home dialysis must
be confined to a minimal disruption of previous family
|process or life style. !
The Need for Patient Responsibility
for Dialysis
I
The results of this study support previous reports
about the need for self-operation in home dialysis. Indi
cations of more dialysis inadequacy and more shunt problems
jwere found in patients who totally relied on someone else
|to operate the dialysis. Chances are that the other person;
|would not be able to give as close care and control to the
;cannula and dialysis process as the patient. For good
resolution of the dependency conflict occurring in dialysis,
the patient must accept his dependency on the machine but
minimize dependencies upon others. Patients who expect !
others to care for them are too regressive. They need to
i
i j
be helped to accept some self-responsibility for their ;
j |
idialysis treatment and ultimate survival.
Although most patients were trained in self-
joperation, only 19%, of the patients primarily handled I
dialysis alone. The majority of the patients, or 62%,
shared the operation with a family member. Since most
310 i
!spouses resent the constrictions and added responsibilities
|of dialysis, one wonders why this is the case. Furthermore,
some helpers were tremendously stressed in assisting and
;had pathological anxieties about making some fatal mishap.
Perhaps the patient is being manipulative in enlisting the
I j
family to help. Perhaps the spouse misguidedly insists on !
; helping.
| In any case the patient should be helped to assume
|full responsibility for the dialysis operation. Family
jmembers should be as little involved in the process as
i !
ipossible. This will insure the best dialysis management,
;increase the patient's self-sufficiency and self-esteem,
land minimize stresses and resentments among the other family
members.
Since it is impossible for some patients to dialyze
themselves if the shunt is located in their preferred arm,
an effort should be made to place the shunt elsewhere.
Some patients were indiscriminately shunted in their
preferred arm without even being asked which hand they
usually use. This practice, without good justification, !
I should be stopped.
The only advantage found in this study for a shunt '
:in the preferred arm was a lessened incidence of dizziness
^during dialysis. This alone would not justify placing the
! shunt in the preferred arm if it impedes self-responsibility
for handling the dialysis. I
[ . .... ’ ~ ' ~ 311 1
j Implications for Psychotherapy |
i i
with Dialysis Patients
The dialysis patient initially needs support from
the medical staff to help him: (a) adjust to the life of
jchronic dialysis, (b) cooperate with treatment requirements^
(c) handle the stresses involved with dialysis, and (d)
overcome his dependency-independency conflicts. The nurses |
|and technicians involved with home training can be the most
iuseful source of psychological support to the new dialysis
i
Ipatient. The patient has the most contact with these staff
(members and will rapidly develop strong rapport and trust
with them. The training staff can discover psychological
jproblems in the patient requiring professional help.
It is possible for the training staff to become too ;
emotionally involved with the patients which results in
frustration or anger at a patient's poor progress or
depression if a patient dies. It would appear to be a
necessary help to team morale and to patient management to
have weekly staff meetings in which the patients are
discussed from a psychological standpoint. The meeting
I should be conducted by some hospital member with psycholog- i
(ical training such as a psychiatrist, clinical psychologist,
i
|or psychiatric social worker. The meetings should be open-
| ended in which the staff can ventilate their feelings about
ithe patient, other staff members, or their own work.
|Different approaches to specific problems with the patient
xan_ be__explored. to_help__ the staff_deal more, effectively I
! 312 |
r 1
j i
with the patients. The. staff meetings can also help the ,
staff members work out their own death attitudes. Failure
of the staff to work out answers to their own death limits
[their effectiveness in helping patients cope with their own
reactions (Cutter, 1970).
Although the renal physicians are generally reluc-
itant to attend this sort of meeting, it is imperative that
they do attend. The staff can help the physician better
[understand the patient and thereby make the physician's
[work easier. Occasionally the physician is insensitive to
|the psychological needs of the patients or the other staff
i
imembers. To develop a smooth running renal team requires
i
total team unity and joint effort.
Psychotherapy should be available to patients as
; needed. Considerations with the quality of life should be
afforded to the dialysis patient whose life is preserved in
a cumbersome and stressful fashion.
Group therapy for the patient or his family is
generally unsuccessful and not helpful. An effort to
establish a dialysis club in the Los Angeles area has been j
[unsuccessful partially because these dialysis patients do j
not want to identify with each other. Many have stated |
; i
ithat they do not want to sit around and hear about the otherj
[patients' dialysis problems. To handle dialysis well j
[requires the development of strong denial which would be !
I j
[constantly eroded in a group therapy setting. Almost half
; .' ...................... 313
i •
lof the spouses stated that they would not join a spouse
|therapy group for similar reasons.
It appears that the most beneficial patient psycho-
itherapy would involve a reality-oriented, short-term
: j
approach on an individual basis. Tuckman (1970) stated
;that brief psychotherapy is well suited to dialysis patients
and that an eclectic approach is essential. This would
jinclude: exploratory and supportive therapy, drug treatment
ifor psychotic episodes, and education and environmental
!
manipulation of the staff and family.
i
| The patient is generally reluctant to seek psycho
therapeutic help for himself. Over 78% of the patients in
|this study had not requested psychological help. With good ;
icommunication, the staff can be alerted to the patient's
ipsychotherapy needs and initiate them. This would include
help with family crises that periodically occur for all
people as well as help for dynamic problems arising from the
dialysis role. Dynamic problems including: depressive
episodes, maladaptive denial, rebellion, dependency
conflicts, etc. would be evidence from sudden or chronic
|management problems or through the patient's statements of |
jinternal distress. j
i In any case, the therapy should be directed to j
' i
j
jdealing with the specific problem and to restoring the
jpatient's ego functions to the precrisis level. The patient!
I !
should be assisted to explore for himself alternative coping
jmethods so that he will be better equipped to handle future
jproblems by himself. This could be accomplished within six
or eight sessions. Short-term psychotherapy would be both
advantageous to the therapist in terms of time involvement,
'and to the patient in terms of not disrupting his adaptive
defenses and in keeping the patient problem-solving oriented.
i
A necessary major consideration in any therapy with
jdialysis patients is the contraindication of breaking down
ihis defenses (Brand & Komorita, 1966). No attempt should
ibe made to substitute a more realistic attitude for the
I
jmassive, adaptive denial (Coogan, 1969). Therefore, it
iwould not seem wise to confront a beginning patient with
'his deeper fears of death, loss of self-image, etc.
Furthermore, some apparent functioning difficulties ;
should be left alone if the patient does not recognize them
as problems. For example, decrease of sexual functioning
!is a problem with chronic dialysis patients. However, since
^denial and rationalization are necessary defenses for good
adjustment as a kidney patient, the implication for patient
management would be to not tamper with the patient's denial
jdefenses and to ignore the problem unless the patient him- !
!self expresses strong distress over a decline in sexual
I i
^performance. Only in the cases where sexual decline is j
; j
causing: marital discord or anxiety, depression, or weak- j
jened self-esteem in the patient would short-term psycho
therapy be indicated and helpful.
i This study supports the evidence that dialysis
patients with a strong denial defense have the best adapta
tion and rehabilitation. The staff needs to be aware of
the need for massive denial with its adaptive and maladap
tive features because they can support the defense when
indicated and keep in focus the reality oriented restric
tions of the patient's illness (Glassman & Siegel, 1970).
Therefore, patients with too little denial who are experi
encing much anxiety and personal distress should be helped
|to develop more denial. On the other hand, if the patient
!
jhas excessive denial to the point of denying his illness or
I
!treatment restrictions, he needs help in lessening the
I |
idenial to an adaptive level.
Helping a patient develop more denial would be '
contrary to analytic process in which the defenses are
slowly chipped away to help the patient become more reality
oriented. However, focusing on dynamic problems of the
dialysis patient would be less helpful in aiding his mastery
:of recurrent crises than a focus on a here-and-now problem-
! solving approach.
; i
; i
Implications for Home Training j
The number of weeks of home training for these j
ipatients ranges from two to eighteen weeks with a mean of |
i
jeight weeks. Patients with either minimal or excessive j
weeks of training before beginning home dialysis generally j
r _ ~ " ~ 3 1 6 1
l !
| had more shunt problems, inadequacy of dialysis, and
|
i specific medical problems. They were also less occupation-
I ally rehabilitated than patients in the middle range of
| training weeks. These results support the statement by
! Eschbach et al. (1967) that a full two months of training
is advisable.
Patients who received the minimum weeks of training!
I before beginning home dialysis were generally higher in
| intelligence. The exceptionally bright patient may be
| released prematurely because he learned the procedures
|rapidly. The results of this study would indicate that
j j
:even if the bright patient has rapidly mastered the
;dialysis techniques, he should be trained a full eight
weeks to avoid latter adaptation and rehabilitation
problems.
Patients with the greatest amount of training weeks
may have more adaptation and rehabilitation problems
because they have not mastered the process. Patients with
;no self-confidence about their ability to handle the
;dialysis had indications of poorer dialysis management in
|terms of specific transient symptoms during dialysis and
|poorer chemistry measures. Perhaps patients should not be
i j
released to the home until they are completely proficient
|in dialysis techniques and until they also develop strong j
j j
|self-confidence about their ability. j
:Implications Regarding Past Research Findings
I Two reasons could explain why many earlier findings
Iwere not verified by this study. First, other studies were
based on small sample populations which may have yielded
biased results. Second, techniques are changing and improv
ing so rapidly in dialysis management that previous findings
are obsolete.
| Some of the following results of this study contra- ■
I diet earlier reports: (a) the independent patient did not
have greater job rehabilitation, (b) the dependent patient
had poorer cooperation with the treatment regime, (c) age,
jintelligence, mechanical aptitude, or family emotional
!support had no relationship to criteria of adjustment or
rehabilitation, (d) patients with a parallel-plate dialyzer
had more transient symptoms during dialysis, (e) there was
no difference between acute and chronic renal failure and
: amount of patient denial or rehabilitation, (f) patients
' i
with cardiac complications did not have less job rehabili
tation, (g) the removal of both kidneys did not cause a
; decrease in sexual functioning or an increase in hyperten
sion or other medical problems, (h) patients with more
i i
I frequent dialyses or more hours per week of dialysis did
|not have less pruritis, (i) patients with greater neuropathy
were not less occupationally rehabilitated, and (j) night- j
|time dialysis did not increase job rehabilitation. !
j 318 '
i •
iImplications for Future Research
i i
I At the time of undertaking this research it was felt
jthat an overview study simultaneously examining many aspects
of dialysis was necessary to get a feeling for the total
picture and problems. The results of this study indicate a
need for future systematic research in various specific
!
areas. Nonmedical selection criteria must be validated as
[predictors of successful adaptation, rehabilitation, or
Ipsychological adjustment to a home dialysis program. The
j :
|use of the MMPI Factor A and R scales and the Picture- :
'Frustration Study for determining healthy denial in dialysis
ipatients should be studied. Further research is needed on
Ithe patient's denial system and if it can be manipulated to
adaptive levels. The use of short-term, reality-oriented
jtherapy to help the patient handle specific crises should be
explored.
Longitudinal studies over time are needed with
patient information obtained prior to dialysis and with
Uniform measures taken at intervals following dialysis.
A major problem in dialysis research is the lack of suffi
cient sample size upon which to draw conclusions. Husek 1
(1967) suggested the need for a central registry of informa-
i
!
tion on dialysis patients in which the population is
I
described in a uniform manner and a continuous census
maintained. This would enable adequate, representative
samples for research.
319 1
This study indicates the need for uniform biochem-
i I
|ical measures taken every three or four months. The
i incidences of shunt problems should also be compiled every
four months. It would be helpful to administer a uniform
psychological test battery to accepted candidates before
beginning dialysis. The WAIS, MMPI with Factor A and R
scales, and the Picture-Frustration Study would probably be
good inclusions to the test battery.
There is a need to standardize criterion measures
i
of adaptation and rehabilitation. Job rehabilitation
i
should be reported in the literature in terms of both !
I current employment and whether there is a decrease in
|employment following dialysis to get an accurate picture of
return to predialysis level.
Since this type of study is relatively uncommon and I
an important interface between psychological and medical
research, it is appropriate to comment on the advantages
land problems encountered in this type of research.
First, as this study clearly shows, adaptation to
chronic illness includes psychological factors as well as |
medical or treatment factors. These factors are interre-
i :
i
llated. Therefore, there is a need for more research of j
I this form when studying medically ill populations in which
| j
psychological and medical factors are analyzed simultane- j
jously and their significance to the problem differentially
parceled out.
| 320
j
I In conducting research in medical areas where the
|sample population is relatively small nationally and where
;few cases exist within a treatment center, the advantage of
spooling cases from different treatment centers together
allows findings to be based on a larger, more representative
I sample. In one instance a center in this study agreed that !
the results of this paper contradicting an earlier publica- j
ition were correct since their previous findings were based
i
| on the initial patients accepted to the program who were
j j
I nonrepresentative of the patients to follow.
I .
! A difficulty of study of this type is in obtaining
i !
I comparable data between treatment centers. Different
centers may record data at different time intervals, use j
1 j
|different laboratory tests, etc. There is a problem of
less control over the data. If the data cannot be statis
tically equated, then the data which must be excluded from
Ithe statistical analyses are lost in terms of overview
completeness.
Although the usual research strategy is to examine i
la narrow specific problem in a highly controlled manner,
I there is much merit to an overview study of this type in j
j •
|initial medical research. An overview study objectively j
; j
jexamining all potential variables simultaneously can:
! (a) yield the best, extensive picture as to what is happen
ing among the patients, (b) prevent unlikely but significant;
|
jvariables from being overlooked, and (c) uncover promising j
areas for future, controlled research.
However, it must be remembered that a study of this
jmagnitude requires a sizable investment in terms of cost
jand time for completion of the research. In new medical
Iproblem areas with rapidly developing technological and
patient management advancements, there is always the possi
bility that the results of a study will be obsolete soon
iafter obtainment. It then becomes a matter of economics
i
|and generality of findings in making a decision to conduct
I
Ian overview, extensive study such as this research project.
I This research was not designed as a final study.
It was hoped that this study would both aid and inspire
i
I future research on home dialysis that would result in a
decrease in the current incidence of dietary, cannula,
i
|dialysis inadequacy, and medical complications and also
; increase the objectivity and validity of the selection
process. It is further hoped that the relationship of
these findings to chronic medical illness in general will
be investigated.
I
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Schreiner, G. E., & Maher, J. F. Uremia; Biochemistry.
Pathogenesis, and Treatment. Springfield, 111.:
Charles C. Thomas, 1961. P. 552.
Schreiner, G. E., & Maher, J. F. Hemodialysis for chronic
renal failure. III. Medical, moral and ethical, and
socio-economic problems. Annals of Internal Medicine.
1965, 62(3), 551-557.
Schribner, B. H. Proceedings, conference to consider the
treatment of patients with chronic kidney disease with
uremia. New York, June 1963. (Processed.)
Schribner, B. H., Buri, R., Caner, J. E. Z., Hegstrom, R.,
! & Burnell, J. M. The treatment of chronic uremia by
means of intermittent hemodialysis: A preliminary
! report. Transactions of the American Society for
Artificial Internal Organs. 1960, VI, 114-121.
jSchribner, B. H., Fergus, E. G., Boen, S. T., & Thomas,
E. D. Some therapeutic approaches to chronic renal
insufficiency. Annual Review of Medicine. 1965, 16.
285-300.
■Schupak, E., and Merrill, J. P. Experience with long-term
intermittent hemodialysis. Annals of Internal Medicine.
1965, 62(3), 509-518.
Schupak, E., Sullivan, J. F., & Lee, D. Y. Chronic hemo
dialysis in "unselected" patients. Annals of Internal
Medicine. 1967, 67(4), 708-717.
|Schwab, J. J., & Harmeling, M. A. Body image and medical |
illness. Psychosomatic Medicine. 1968, 30.(1), 51-61.
jShaldon, S. Independence in maintenance hemodialysis. j
I Lancet. 1968, .1, 520-523. (a) j
! j
jShaldon, S. Chronic haemodialysis. Phvsiotheraov. 1968,
| 54, 14-16. (b)
jShaldon, S. Emotional problems in a chronic haemodialysis
unit. Lancet, 1968, 2., 1347. (c)
jShambaugh, P. W., Hampers, C. L., Bailey, G. L., Snyder,
D., & Merrill, J. P. Hemodialysis in the home--
emotional impact on the spouse. Transactions of the
American Society for Artificial Internal Organs. 1967,
i XIII. 41-45.
Shambaugh, P. W., & Kanter, S. S. Spouses under stress:
Group meetings with spouses of patients on hemodialysis.
American Journal of Psychiatry. 1969, 125.(7), 928-936.
Shapiro, F. L., Messner, R. P., & Smith, H. T. Satellite
hemodialysis. Annals of Internal Medicine. 1968,
69(4), 673-684.
|Shaw, A. B., Bazzard, F. J., Booth, E. M., Nilwarangkur, S.,
i & Berlyne, G. M. The treatment of chronic renal
j failure by a modified Giovanetti diet. Quarterly
Journal of Medicine. 1965, 134. 237-253.
! '
I Shea, E. J., Bogdan, D. F., Freeman, R. B., & Schreiner,
G. E. Hemodialysis for chronic renal failure. IV.
i Psychological considerations. Annals of Internal ;
| Medicine. 1965, 62(3), 558-563.
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| hemodialysis. Archives of General Psychiatry. 1969,
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I j
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I ;
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i !
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| 65, 42-44. |
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| Annals of Internal Medicine. 1966, 64(3), 611-621.
i
I
APPENDICES
I
|
336
APPENDIX A
QUESTIONNAIRE FOR HOME DIALYSIS PATIENTS
Patient Number______
1
1. My age is _____ years . !
2. Sex _____(0) male _____ (1) female
3. Average weight is ______ lbs. j
4. List the last year of school completed and diploma or
degree. _______________________________________________ I
5. My treatment hospital is about miles from my home. |
6. Does your treatment hospital have a psychiatrist,
psychologist, or social worker available to talk to if
you feel troubled? (1) yes _(0) no i
7. Have you ever requested this service?
(1) yes _____ (0) no
8. The type of dialysis membrane I use is a: j
I
(1) Kiil _____(3) Twin coil j
(2) Single coil _____(4) Chronic coil
9. The name of the dialysis machine I have is a: j
(1) MAKS 900______________(4) MAKS 990A '
(2) Drake Willock_________(5) other (give name)
(3) Milton Roy __________________________
10. Do you use a blood pump during dialysis?
(1) yes _____ (0) no
11. How many months passed before you first noticed I
symptoms after being told you had kidney disease? j
__________months. j
When did symptoms first appear? _______________________ |
month year
What were these symptoms?______________________________ i
| 338 I
12. How many months passed between the onset of these
symptoms and your first dialysis (either peritoneal or j
hemodialysis)? months
13. Number of peritoneal dialyses I had. times
Date of first peritoneal dialysis. j
month year
1
;14. Number of weeks between first peritoneal dialysis and
first hemodialysis. weeks
Date of first hemodialysis in hospital. ______________
month year !
; 15. Number of hospital dialyses per week. _____
! Approximate hours each time. _____
| Number of hours per week of hospital dialysis. ______
j 16. Number of weeks of hemodialysis before beginning train
ing for home dialysis . weeks
j 17 . Number of weeks of home training. weeks
j :
18. Total number of training hours. hours
j 19. How long have you been dialyzing at home?
years and months Total months_________
! I began home dialysis on ____________________.
month year
20. Number of hours per week on home dialysis. ________hours;
21. Current number of dialyses during a two-week period.
22. Check the phrase that best describes your dialysis
schedule:
(1) I dialyze primarily during the day.
(2) I dialyze about equally during the day & night.
(3) I dialyze primarily during the night. j
Describe the weekly schedule of your dialysis treatment!
including days and approximate time of day. (Example:
Monday and Thursday, 8:00 p.m. to 4:00 a.m.)___________
_ 339 I
[ .
|23. When on dialysis, mainly: (check appropriate sentence)
! _______ ___(1) My spouse or another person operates the
equipment.
(2) I share the operation of the equipment about
equally with my spouse or another person.
(3) I operate the equipment.
If your spouse does not help you, who does?___________
124. During dialysis, I fall asleep (check one).
j _____ (5) always
| (4) frequently
j _____(3) about half the time
! (2) occasionally
; (1) never
;25. Check the appropriate phrase:
i (1) I expect to remain on home hemodialysis.
! (0) Home hemodialysis is a temporary procedure
j until a kidney transplant is available to me,
;26. List the approximate number of hours per week spent in
| preparing and cleaning dialysis equipment.
j Hours spent per week by myself (3) patient
1 Hours spent per week by others (2) equal
Total _____ (1) other
27. Do you keep fairly accurate and complete records of
your home hemodialysis? _____(1) yes _____ (0) no
I 28. Do you take any medication for your '’nerves" or for
sleep? _____(1) yes _____ (0) no
29. If you cut yourself, does the cut take longer to stop j
bleeding or do you lose more blood than before
dialysis? (when not using heparin or coumadin)
(1) yes _____ (0) no
!30. Check the phrase that best describes the amount of !
urine you presently void in a 24-hour period. j
I (3) I make 800 cc. of urine or more in a 24-hour j
period. i
(2) I make less than 800 cc. of urine but more !
I than 1 ounce in a 24-hour period. j
(1) I make less than 1 ounce of urine in a 24-hour
period. j
! 340 l
|31. If you make less than 800 cc. of urine in a 24-hour
period, how many months ago did your level drop under
j 800 cc . ? months
List the date this happened. ________________________
month year
|32. How many times have you or your helper declotted your
shunt outside of the hospital in the past 3 months?___
!33. Check the word that describes your current marital
status. _____(1) married (0) not married
I ;
'34. How many children do you have?
(0) none _____ (1) one or more
35. How many children do you have who are under 16 years
i of age? _____
|36. How many children of any age live at home? _____
|37. I have been married to my present spouse for _____
; years.
|38. How do you rate the happiness of your present marriage
| before hemodialysis? (check one)
(7) extremely happy _____ (3) slightly unhappy
(6) quite happy (2) quite unhappy
(5) slightly happy (1) extremely unhappy:
(4) neither happy (0) not married then ;
nor unhappy
39. How do you rate the current happiness of your present
marriage since hemodialysis? (check one)
(7) extremely happy_________(3) slightly unhappy
_____(6) quite happy_________ ____(2) quite unhappy j
(5) slightly happy__________(1) extremely unhappyj
(4) neither happy___________(0) not currently
nor unhappy married
j 40. Check the sentence that best describes your feelings
! about the help of your spouse (parent).
(0) Generally helps me or wants to do things for !
me more than I would like. !
(1) Generally helps me or wants to do things for
me about equal to the amount of help I like, j
(2) Generally helps me or wants to do things for
me less than I would like.
41. How would you rate the amount of emotional support, !
I understanding, and encouragement your spouse (parent)
gives you to that received by other home dialysis '
patients?
(5) superior (2) below average
(4) above average ____ (1) poor
(3) average
I 42. Check the phrase that best describes your current
sexual performance compared to your preillness ability]
(4) increased (1) decreased
(3) stayed the same markedly
(2) decreased slightly _____(0) ceased
I 43. Speaking for the way I feel about it, I find my
i current sexual performance:
| (1) satisfactory _____ (0) unsatisfactory
j 44. If your sexual performance has ceased, how many months!
! ago did this occur? months ago
|45. Check the category that best describes the kind of
work you have done most of your life.
i j
(9) Professional (job requiring college degree).
(8) Semi-professional (job requiring over 1 year
of specialized schooling. Example:
programmer, artist, dental assistant, writer).
(7) Store owner or manager or business owner.
(6) Sales or clerical work.
(5) Craftsman, foreman, skilled machinist,
mechanic, repairman, etc.
(4) Factory production--assembly line work or
operator of machine for mass production of
goods.
(3) Construction work--welder, plasterer, painter,
plumber, or drive equipment used in excava
tion, paving, etc.
(2) Services--waitress, bartender, hairdresser,
j gardener, guard, janitorial, domestic worker, ;
i housekeeper, delivery man, bus driver,
J trucker. i
! (1) Unskilled labor--stockboy, shipping clerk, '
| loader, shoveler, etc. j
| (0) Unemployed or housewife.
46. How much time do you generally put in at work now? j
(Housewives answer, too.) j
_____ (0) unemployed
(1) 1 to 16 hours per week
342
.(2) 17 to 24 hours per week
_(3) 25 to 32 hours per week
,(4) 33 to 40 hours per week
.(5) 41 to 48 hours per week
.(6) over 48 hours per week
|47. Do you currently work noticeably fewer hours than
before hemodialysis? (Housewives answer, too.)
; (1) yes _(0) no
148. Did you have to change your occupation because of
| hemodialysis? (1) yes (0) no
j49. My spouse is currently employed:
j _____ (3) full-time
(2) part-time
_____ (1) not employed
(4) more than full-time
Before dialysis my spouse was employed:
(3) full-time
_____(2) part-time
(1) not employed
(4) more than full-time
;50. Check the figure that best describes your combined
annual income:
! _____(1) under $3,000
(2) $3,001-$5,000
(3) $5,001-$10,000
I _____(4) $10,001-$15,000
(5) $15,001-$20,000
(6) over $20,000
51. What per cent of your annual combined income does
dialysis cost you for expenses and supplies?
(6) My dialysis costs are more than my annual
! income.
| (5) My dialysis costs are 80-100% of my annual
income.
! (4) My dialysis costs are 60-80% of my annual
! income.
| (3) My dialysis costs are 40-60% of my annual
i income.
(2) My dialysis costs are 20-40% of my annual
income.
(1) My dialysis costs are 0-20% of my annual
income.
343 !
52. How often do you have trouble falling asleep or in
waking up in the night and being unable to go back to ;
sleep?
(4) always (1) occasionally
(3) frequently (0) never !
(2) about half the time
53. Since beginning hemodialysis have you ever had mild
tingling or numbness in your hands or feet?
(1) yes _____ (0) no
54. How severe has this been during the past 3 months com-;
pared to the amount of numbness or tingling you had
when you first began hemodialysis?
(3) It is now more severe.
(2) It is now the same as when I began dialysis.
(1) It is now less severe.
(0) It has been absent the last 3 months.
55. Since beginning hemodialysis have you ever had "burn
ing" feet? (1) yes (0) no
56. How severe has this been in the past 3 months compared
to the amount of "burning" you had when you first
began hemodialysis?
(3) It is now more severe.
(2) It is now the same as when I began dialysis.
(1) It is now less severe.
(0) It has been absent the past 3 months.
57. Since beginning hemodialysis have you ever experienced
uncontrollable restlessness, or agitation or twitching
of your legs? _____(1) yes _____ (0) no
58. How severe has this been in the past 3 months compared
to the amount of restlessness or twitching of your
legs when you first began hemodialysis?
(3) It is now more severe.
(2) It is now the same as when I began dialysis.
(1) It is now less severe.
(0) It has been absent the past 3 months.
59. Since beginning hemodialysis have you ever experienced;
muscle weakness or paralysis in your feet or legs? 1
(1) yes _____ (0) no j
60. How severe has this been in the past 3 months compared
to the amount of muscle weakness or paralysis in your
j legs when you first began dialysis?
(3) It is now more severe.
(2) It is now the same as when I began dialysis.
(1) It is now less severe.
i ______(0) It has been absent during the past 3 months.
;61. Since beginning hemodialysis have you ever been
bothered by intense "itching" skin?
(1) yes _____(0) no
62. How severe has this been in the past 3 months compared
to the amount your skin itched when you first began
dialysis?
| (3) It is now more severe.
I (2) It is now the same as when I began dialysis.
i (1) It is now less severe.
I ___________ (0) It has been absent during the past 3 months.
i
’63. How would you rate your current level of happiness
I compared to other people in general?
I (0) more unhappy
(1) average
I (2) definitely happy
(3) extremely happy
64. How would you rate your current level of happiness
compared to other kidney patients?
(0) more unhappy
(1) average
(2) definitely happy
(3) extremely happy
1 65. My shunt is currently located in:
(1) an arm (0) a leg
66. Is the shunt located in your preferred arm?
(1) yes _____(0) no
I (To be filled in by male patients.) !
i j
67. How do you feel about your wife working since dialysis !
! where she was not before? i
i
(0) Does not apply; she worked before. i
(1) Dislike her working very much. j
(2) Dislike her working somewhat.
(3) No feelings one way or the other.
345 I
j _____(4) Like her working somewhat. j
(5) Like her working very much.
168. I worry about our financial situation:
i !
(1) Very much or all the time.
(2) Somewhat or frequently. j
■ (3) Little or occasionally. !
! (4) Not at all.
169. How do you feel about having to be less active or do
less of the things you used to because of dialysis? j
, (1) Very unhappy. !
(2) Somewhat unhappy.
(3) No feelings one way or the other. j
! (4) Somewhat happy.
| (5) Very happy.
| (0) Does not apply; I do as much as before
| dialysis.
170. How do you feel about having to schedule your life and
| activities around your dialysis sessions?
!
(1) Dislike very much.
i _____ (2) Dislike somewhat.
(3) No feelings one way or the other. ;
(0) No problem since it doesn't interfere with
my activities.
71. How confident are you about your ability to run the
j dialysis machine and to be able to handle any problem
or emergency that might arise?
(6) Extremely sure of myself.
(5) Very sure of myself. j
(4) Somewhat sure of myself. j
(3) Neither sure nor unsure of myself. i
(2) Somewhat unsure of myself. j
(1) Very unsure of myself. I
i i
72. If someone helps you run the dialysis machine, how
confident do you feel about this person's ability to I
operate the machine during dialysis and to be able to
handle any problem or emergency that might arise?
(6) Extremely sure of this person. j
| (5) Very sure of this person. j
(4) Somewhat sure of this person. i
| (3) Neither sure nor unsure of this person
(2) Somewhat unsure of this person.
! (1) Very unsure of this person.
How do you feel about dialysis?
(5) Benefits greatly outweigh hardships.
(4; Benefits somewhat outweigh hardships
(3) Hardships equal to benefits.
(2) Hardships somewhat outweigh benefits
(1) Hardships greatly outweigh benefits.
WEIGHT LOSS BEFORE AND AFTER DIALYSIS
|Go back over your records for the past 3 months.
|List each weight loss following dialysis for each dialysis
!during this time.
Record the weight loss to 1/2 lb. if you measure it this
iclosely.
EXAMPLE: (for dialysis 3 times per week)
Week 1 3 0 _____ _____
Week 1 lbs. lbs. lbs. lbs. lbs.
Week 2 lbs. lbs. lbs. lbs. lbs.
Week 3 lbs. lbs. lbs. lbs. lbs.
Week 4 lbs. lbs. lbs. lbs. lbs.
Week 5 lbs. lbs. lbs. lbs. lbs.
Week 6 lbs. lbs. lbs. lbs. lbs.
Week 7 lbs. lbs. lbs. lbs. lbs.
Week 8 lbs. lbs. lbs. lbs. lbs.
Week 9 lbs. lbs. lbs. lbs. lbs.
Week 10 lbs. lbs. lbs. lbs. lbs.
Week 11 lbs. lbs. lbs. lbs. lbs.
Week 12 lbs. lbs. lbs. lbs. lbs.
348 |
i |
| TRANSIENT SYMPTOMS DURING DIALYSIS
i l
i Below is a list of symptoms that patients experience during:
j dialysis.
| Check the usual severity of each symptom that you generally!
! experience. j
I
! SYMPTOM USUAL SEVERITY EXPERIENCED ;
| (0) Absent (1) Mild (2) Severe
| j
76. Nausea j
j
77. Vomiting _____ _____ _____
i j
1 i
! 78. Leg muscle cramps ;
i 79. Headache _____ _____ _____
80. Dizziness i
i
; |
81. Drowsiness or j
sleepiness _____ _____ _____
: i
! 82. Restlessness i
| 83. Irritability !
I 84. Irregular heartbeat ______ j
DAY AFTER DIALYSIS EFFECTS j
i !
] !
| Below is a list of symptoms patients experience on the day s
I following dialysis. I
I Check each symptom as to whether it is usually: 0) absent:I
; 1) mild: or 2) disabling enough so that you are unable to
: work or do your usual activities.
i SYMPTOM USUAL SEVERITY EXPERIENCED DAY AFTERi
; i
I — ■■■ — 1 — ■ ... ■ i
i ;
(0) Absent (1) Mild (2) Disabling!
j
85. Listlessness _____ _____ _____
86. Irritability__________ _____ _____ _____
87. Nervousness _____ _____ _____
| 88. Feeling "blue"
or Mlow spirits" j
| 89. Headaches |
■ 90. Leg muscle cramps _____ ;
I 91. Sleepiness or j
| drowsiness j
| 92. Nausea _____ _____ _____
; 93. Vomiting ' j
|94. Restlessness j
I j
195. Low blood pressure _____ |
; |
i 96. Dizziness j
!Please add any additional information about the situation
lor problems of home dialysis patients or about this ques-
Itionnaire__________________________________________________
jThank you for your cooperation.
APPENDIX B
| SPOUSE QUESTIONNAIRE j
i i
|We would like to know what effects your spouse's illness j
|has had on you and your family life. Your frank answers to!
|these questions can help us better understand the problems i
|of hemodialysis.
i !
| Please answer freely as this information will be kept confi-j
jdential and used anonymously only for research purposes.
* I
jDisregard the numbers in parenthesis which are for computerj
purposes. !
i
I j
| Patient Number___________ |
! j
! Date_____________________
il. During dialysis who mainly operates the equipment?
| (Check the appropriate phrase.)
j _____(3) I operate the equipment.
i _____(1) The patient operates the equipment.
(2) I share the operation of the equipment about
equally with the patient.
! (3) Another person operates the equipment.
(Describe who)_________________________
j2. Check the phrase that best describes your spouse's
current sexual performance compared to his (her) pre
illness ability.
j _____ (4) increased
(3) stayed the same
(2) decreased slightly
l _____ (1) decreased markedly
| (0) ceased
3. Check the sentence that best describes your feelings
about the amount of help the patient wants from you.
351
(0) Generally the patient wants me to help or do
more things than I would like.
(1) Generally the patient wants me to help or do
things about equal to the amount I want to do
(0) Generally the patient wants me to help or do
less than I would like.
In general how much time do you currently spend with
your spouse compared to the amount before dialysis?
(5) All free time __(2) About the same
(4) Great deal more ____ (1) Less
(3) Somewhat more
Have the needs of your spouse's illness required you
to drop any social activities, hobbies, or recrea
tional activities? _____ (1) yes _____(0) no
How much do you miss these activities?
(1) Very much ____ (5) Hardly at all
(2) Much _____(6) Not at all
(3) Somewhat ____ (7) Does not apply; no
(4) Little activities given up.
How much of your nonworking time is involved in dialy
sis work (cleaning equipment, preparing special foods,
helping spouse with self-care, etc.)?
(1) 80-100% of free time
(2) 60-80% of free time
(3) 40-60% of free time
(4) 20-40% of free time
(5) 0-20% of free time
To what extent is your spouse more unreasonable, self-
centered, short-tempered, or demanding since dialysis?
(1) all the time (4) rarely
(2) most of the time ___(5) not at all
(3) some of the time
How do you get along with your spouse compared to
before dialysis?
(5) much better___________(2) somewhat poorer
(4) somewhat better ____ (1) much poorer
(3) the same
Since dialysis have you had to take a more active role
in managing the home, caring for the children, or
making decisions? _____ (1) yes _____ (0) no
353 !
11. How do you feel about this shift in roles?
(1) very unhappy (5) somewhat happy
(2) somewhat unhappy ____(6) very happy
(3) slightly unhappy ____(7) does not apply;
(4) slightly happy no role shift.
|12. How much of an effort is it to care for your family
and handle this additional responsibility?
(7) does not apply; no additional responsibility.
; ____(6) very easy
(5) somewhat easy
i ____(4) slightly easy
i ____(3) slightly difficult
(2) somewhat difficult
(1) very difficult
|13. How frustrating is it for you to have to cancel plans
I or social activities because your spouse suddenly does
I not feel well?
extremely frustrating
greatly frustrating
(3) moderately frustrating
(4) hardly frustrating
(5) not at all frustrating
(6) does not apply; no activities canceled.
14. How has the illness affected the closeness you feel
with your spouse?
(6) extremely closer now
(5) much closer now
(4) slightly closer now
(3) slightly further apart now
(2) much further apart now
(1) extremely further apart now
15. How easy do you now find it to express your personal
emotional feelings to your spouse?
! (6) extremely easy _____(3) somewhat difficult
(5) very easy ____(2) very difficult
(4) somewhat easy ____(1) extremely difficult
16. Check the phrase that best describes how sexually
J attractive you find your spouse compared to before
j dialysis.
| (4) more attractive _(1) markedly less
(3) same as before attractive
| (2) slightly less _(0) complete loss of
! attractive interest
354
1 17. How do you feel about your current sexual life with
your spouse?
I _____ (1) satisfactory _____ (0) unsatisfactory
; 18. How would you rate the happiness of your marriage
I before dialysis?
(7) extremely happy (3) slightly unhappy
j _____ (6) quite happy (2) quite unhappy
(5) slightly happy (1) extremely unhappy
(4) neither happy
{ nor unhappy
{19. How would you rate the current happiness of your
| marriage since dialysis?
(7) extremely happy (3) slightly unhappy
_____ (6) quite happy (2) quite unhappy
(5) slightly happy (1) extremely unhappy
(4) neither happy
nor unhappy
|20. How is your current health compared to your health
| before your spouse's dialysis?
(2) better ____(1) same ____(0) worse
j
{21. Compared to before home dialysis, do you currently
feel more tired or run down? (1) yes (0) no
i — —
22. Compared to before home dialysis, do you currently get
more colds or minor illnesses? ___(1) yes ___(0) no
23. Compared to before home dialysis, do you currently get
more headaches? ____(1) yes ____(0; no
{24. Compared to before home dialysis, do you currently
1 feel more depressed or in "low spirits"?
(1) yes _(0) no
25. Compared to before home dialysis, do you currently
| feel more frequently nervous or anxious?
| (1) yes _(0) no
;26. Do you regularly take any medication for your nerves
! or sleep? _____ (1) yes (0) no
j
27. Compared to before home dialysis, do you currently
{ have more trouble falling asleep or in waking up in the
I night and being unable to go back to sleep?
| (1) yes (0) no
! ... 355 ! .
i i
| 28. Does your treatment hospital have group sessions for !
I the spouses of dialysis patients to talk about mutual j
problems and to exchange ideas? ;
j _____ (1) yes _____(0) no _____ (9) do not know
|29. Would you regularly attend such sessions if these were j
| available? (1) yes _____ (0) no
! I
i 30. How would you rate your current level of happiness
compared to people in general?
I _____(0) more unhappy _____ (2) definitely happy
; (1) average _____(3) extremely happy
31. How would you rate your current level of happiness
compared to spouses of other kidney patients?
i
1 j
! (0) more unhappy _____ (2) definitely happy j
! (1) average _____(3) extremely happy j
|32. I worry about our financial situation: i
J _____ (1) very much or all the time j
! (2) somewhat or frequently J
| (3) little or occasionally i
j _____(4) not at all |
133. How do you feel about having to schedule your life and
activities around the dialysis sessions? j
(1) dislike very much
(2) dislike somewhat
| (3) no feelings one way or the other :
(0) no problem since it does not interfere with !
my activities
i
34. If you assist in running the dialysis machine, how !
| confident are you about your ability to run the j
dialysis machine and to be able to handle any problem j
or emergency that might arise? j
(6) extremely sure of myself j
I (5) very sure of myself !
(4) somewhat sure of myself !
! (3) neither sure or unsure of myself i
| (2) somewhat unsure of myself j
! (1) very unsure of myself I
(0) does not apply; I do not assist in running the!
machine j
356
|35. How do you feel about dialysis?
{ (5) benefits greatly outweigh hardships
| (4) benefits somewhat outweigh hardships
j _____ (3) hardships equal to benefits
j _____ (2) hardships somewhat outweigh benefits
| (1) hardships greatly outweigh benefits
1 36. Has hemodialysis caused significant problems for the
j children?
| (1) yes ____ (0) no (0) does not apply; no
| children
What special problems do you have as a spouse of a kidney
patient ?___________________________________________________
Describe any problems hemodialysis causes for the children j
in the family?___________________' _________________________ !
i
What other things should we have asked about to better
understand the effects of hemodialysis on family life?
I
|.
|Thank you for your cooperation.
i
I
APPENDIX C
STAFF EVALUATION OF PATIENT'S ADJUSTMENT
TO CHRONIC HOME HEMODIALYSIS
| We would like you to compare_________________________________i
jto the other home hemodialysis patients in your unit. Do
[not use patients who regularly dialyze in the hospital as
la basis of comparison.
j i
I Circle the appropriate word for each question that best !
|describes this patient. If you do not have the information I
for a particular question leave it blank, but try to answer
every question. Please answer freely as this information i
will be kept confidential and used only for research
purposes. Disregard numbers in parenthesis used for I
computer purposes.
!
1. How many months have you worked with this patient? !
2. Approximately how many times a month do you see or talk !
with this patient? __________ I
3. In general, how would you classify this individual's
cooperation with medical requirements? How would you j
classify this person's cooperation in working for his j
own successful treatment? j
(3) superior _____(2) adequate _____ (1) poor
4. How would you classify his emotional adjustments to
living as an artificial kidney patient?
(3) superior _____(2) adequate _____ (1) poor j
5. If you were making decisions about the acceptance of
future patients would you recommend accepting another
patient who closely resembles this patient?
(2) yes _____ (1) no
6. How would you classify this patient in seeming to be
happy and leading a normal life?
(3) superior _____(2) average _____ (1) poor
357
___ _ 358 n
7. How would you classify the emotional support and j
understanding this patient receives from his family? ;
(3) superior _(2) average ________ (1) poor
' 8. How would you classify this patient in showing motiva- j
j tion to be a productive member of the community? !
(3) superior _(2) average ________(1) poor
jThe following questions deal with this person's general
behavior. We would like to know how this behavior compares i
jto the behavior of the other home hemodialysis patients.
j :
| Yes (1) No (2) \
I I
9. Does this person tend to get more
upset when things go wrong?_____________ ____ _____ ;
jlO. Is this person generally more
■ depressed? ____ _____ |
i !
t 1
|11. Is this person generally more
anxious or worried?__________________________ _____ !
12. Is this person more frequently
| or easily irritated?
|l3. Is this person more dependent and
I reluctant to do things for himself?
|14. Is this person more independent and
j resentful or resistant to reason
able assistance?
;15 . Does this person demand more
attention or favored handling? _____ ___
i
116. Describe any management problems this patient or his
| family presents.______________________________________
17. Putting professional attitudes aside, how would you j
i rank your liking of this person in comparison to your j
! personal feelings for the other patients?
(3) greater _____ (2) average (1) less
359
Do not i
Yes (1) No (0) know (9) j
18. Is impotency or decreased I
sexual activity a frequent
occurrence with home
dialysis? _____ _____ _____
i
19. Has impotency or decreased
sexual activity been a
problem with this patient?_________ j
20. Do you ever discuss this I
with the patient? ____ _____ !
j
21. What do you see as the causes of this problem for this |
patient? (List minor causes as well as major
reasons.) (1) T (0) G
j 22. Have you ever told or indicated to this patient that j
| impotency or decreased sexual activity is a common ■
occurrence with dialysis? _____ (1) yes (0) no
i '
| !
:Additional comments regarding the patient or this question- :
inair e_________________________________________________________ ;
Thank you for your cooperation in helping us to try to
better understand factors relating to better adjustment of
patients who dialyze at home.
i
i
APPENDIX D
MEDICAL INFORMATION OF HOME HEMODIALYSIS PATIENT
!This information will be used only for research purposes
|specific to this study and will be held confidential to be
I destroyed upon completion of this study.
i
1 Please answer all questions.
Patient's name Today's date
1. The patient has been on home dialysis _________ months.
2. Number of hours of home training ______ hours.
| 3. Total number of hours of home dialysis per week
i hours.
! -----
I 4. The patient's schedule of home dialysis is: (check
one)
| _____(2) one time per week
(4) two times per week
! _____(6) three times per week
I _____(8) four or more times per week
| _____(3) irregular but 3 times in 2 weeks
! _____(5) irregular but 5 times in 2 weeks
! _____(7) irregular but 7 or more times in 2 weeks
j or every other night
I 5. The patient's shunt is current on the arm leg.
!
! 6. Is the patient's shunt on the preferred arm?
! _____(1) yes _____ (0) no
| 7. Patient's renal disease(s) are: (check one)
| (1) acquired__________ (0) congenital
I 8. How many kidneys have been removed from the patient?
j _____(0) None, both intact
| _____(1) One kidney removed
I _____(2) Two kidneys removed
360
361
|
9. Has this patient ever had a kidney transplant? j
(1) yes ______(0) no
10. Is this patient medically suitable for transplant? j
j
(1) yes _____ (0) no I
11. The serum creatinine value at the time the patient
began dialysis was ________________________ . j
12. Does the patient frequently lose more than 1 kg. weightj
loss after dialysis? j
(1) yes _____ (0) no
CANNULA PROBLEMS
Please list the number of times each cannula problem has
occurred within the past 3, months.
Problem
Frequency during
past 3 months
13. Surgical repair of artery times
u. Surgical repair of vein times
15. Shunt clotting times
16. Shunt accident or disengagement times
17. Shunt infection times
IBIOCHEMICAL CONTROL |
| |
jFor the following list of biochemical measures, list: 1) I
jthe frequency of occurrence during the past 3. months: and j
|2) the number of times the measure was taken during the j
Ipast 3. months. If no laboratory test nor records exist for j
the past 3 months, write NO DATA in the frequency blank. !
362
Measure
18. Predialysis serum potassium
| over 6.5
1 19. Serum albumin below 3.5
i exclusive of illness or
! infection
j
20. BUN over 90.0
21. Serum creatinine over 16.0
22. Predialysis phosphate
over 10.0
23. Predialysis uric acid
over 9.0
Number of
occurrences
in past
3 months
times
_times
_times
.times
.times
times
Number of j
measures S
taken in I
past 3
months !
times
times
times j
times !
times
times !
24. Since entering dialysis, this patient's current
i neuropathy is: (check one)
j _____ (2) improved _____(1) same _____ (0) worse
j
25. Total number of days in the hospital in the past 3
months: days of hospitalization.
[26. Number of direct suicide attempts in the past 3 months
j requiring medical treatment: ___________ times.
[27. Has the patient ever had hypertension during dialysis
[ within the past 3 months (diastolic pressure over 110
| during dialysis or if predialysis pressure near 110 an
increase of 10 points during dialysis?
| (1) yes (0) no
|
28. Has the patient ever had hypotension during dialysis
within the past 3 months where the diastolic pressure
dropped below 60 during dialysis?
(1) yes (0) no
363
i
[MEDICAL COMPLICATIONS
Check all the following medical complications that have
occurred at any time during the past 3. months.
j 29.
130.
! 31-
1 32.
j 33.
34.
35.
36.
37.
38.
|39.
I
>40.
|41.
i
42 •
43.
.(1
.(1
.(1
.(1
.(1
.(1
. ( 1
. ( 1
. ( 1
.(1
.(1
. ( 1
.(1
. (1
. ( 1
Renal osteodystrophy
Sensory peripheral neuropathy
Motor peripheral neuropathy
Pruritis
Impotence
Irregular menses
Anemia
Hepatitis
Hypertension requiring medication
Gastrointestinal bleeding
Peptic ulcer identified by X-ray
Bleeding from urinary tract
Sepsis
Myocardial failure or congestive heart
failure or pulmonary edema
Coronary insufficiency
jThank you for your cooperation in completing this form.
Please add any comments you wish to make about this patient
or the questionnaire.________________________________________

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Asset Metadata

Creator Sviland, Mary Ann Petrich (author)

Core Title Factors Of Adaptation And Rehabilitation In Home Hemodialysis

Degree Doctor of Philosophy

Degree Program Psychology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,psychology, clinical

Format dissertations (aat)

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Marston, Albert R. (committee chair), Barbour, Benjamin H. (committee member), Wolpin, Milton (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c18-544109

Unique identifier UC11363155

Identifier 7203798.pdf (filename),usctheses-c18-544109 (legacy record id)

Legacy Identifier 7203798

Dmrecord 544109

Document Type Dissertation

Format dissertations (aat)

Rights Sviland, Mary Ann Petrich

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA