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REFLECTION
I found this interview one of the most interesting I have had as a medical student. The
patient had a long history of renal problems, with a renal transplant 20 years ago, and
a recent diagnosis of a malignancy. Like many patients with chronic conditions, in
giving his medical history, he was also giving me the story of his life. His kidney
problems had greatly altered the path of his life. His condition had robbed him of his
health for many years, and cost him his marriage and his job. Yet he remained
positive and optimistic. I found this quite humbling, and as the course of the interview
went on I found myself ever more engaged in the story and the patient.

My patient was very keen to share his story. He was an engaging storyteller and I
found his story fascinating. I did not want to interrupt the flow of the conversation, so
would let him speak uninterrupted. I felt this meant I lost my line of questioning at
some points in the conversation. I missed some key details such as a detailed drinking
and smoking history. Despite this, I feel it is essential to listen as fully as possible to a
patient's story - it is crucial to building rapport and hearing these amazing stories is
one of the most interesting aspects of medicine. However, this does not mean that I
should lose track of the task at hand, which is taking a medical history. Perhaps rather
than simply listening to the patient, I should guide the patient through their story,
making sure I pick up the relevant information on the way.

The patient was very clear and eloquent in describing his condition. He would give
full answers to my questions and was very open. This meant that at first I found the
interview fairly straight-forward. However, when I asked the patient about his dialysis
and transplant, the interview began to feel far less 'clinical' and became very personal
and emotional.

The patient became very emotional talking about receiving his transplant. He spoke
about feeling bad that another female patient did not receive the transplant he did. I
could see his eyes filling with tears as he thought about her, some 20 years later. He
said 'I hope she is alright' and then paused. I cannot remember exactly what I said in
response to this, I may not have said anything. I am still not sure what I could have
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said to comfort him. I would like to always know what to say in difficult situations
like this, in order to comfort the patient. Hopefully this will come with experience.

The patient also became emotional talking about the recent delay in his cancer
diagnosis. He seemed angry and frustrated by the unnecessary tests and the time he
spent waiting in anguish. I remember he asked me directly: "that isn't very good is
it?". I remember feeling quite defensive about the medical profession, and said
something like "sometimes it can be very difficult to find out what's going on, I'm
sure the doctors were doing all they could". This response was probably not very
comforting; I remember thinking that he was not very impressed with my response,
that it was fairly predictable. However, I think maybe that he was not really interested
in the response to the question; that he just wanted to express his frustration.

I asked open questions throughout the interview. I tried to keep a logical and
chronological structure to the interview as I have found this helps me keep track of
the questions I should ask. I tried to focus on the presenting complaint as fully as
possible at the start, although it was clear that the patient was most happy talking
about his past medical history and what had happened many years ago. I do not feel I
missed any significant features of the presenting complaint, however the information I
gathered was not as thorough as I would have liked.

I felt the patient responded very well to encouragement, both verbal and non-verbal. I
feel my active listening throughout the interview was very good. He especially liked it
when I told him how interesting I found his story. By encouraging throughout the
interview, I feel I got a thorough understanding of the patient and his illness and
explored all the topic areas.

The patient said he enjoyed speaking to me, and was pleased to share his story. He
said I listened very well, but felt he was rambling slightly at some points. He thought
the interview felt like a conversation rather than an interview, which pleased me.
Although I did not get some of the details, I would like in the future for my history
taking to feel fairly conversational, rather than like an interview. Medicine is all about
the interaction between the doctor and patient, and it is important that this interaction
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feels as natural as possible. I should, however, be careful of ensuring I gather all
relevant clinical information in the flow of the conversation.


PSYCHOLOGICAL EFFECTS OF HAEMODIALYSIS

INTRODUCTION
End-stage renal disease (ESRD) is a chronic condition that greatly impacts the
patients life. It requires haemodialysis: a time-consuming and intensive treatment
that causes dramatic changes in the patients quality of life. This short paper considers
haemodialysis, and its psychosocial impact, in the context of a 56-year-old man (AD)
who underwent 5 years of haemodialysis, prior to receiving a kidney transplant.

CASE STUDY
The experience of having ESRD failure and haemodialysis greatly altered the course
of ADs life. Three times a week, he would stay at the hospital overnight to have his
treatment. Over five years, his condition and treatment cost him his health, his
marriage and his job. He spoke of the terrible physical side effects of his renal failure
and dialysis. Some days after dialysis he would feel so exhausted that he could hardly
move, yet he was still expected to go to work as a delivery driver. His teeth were like
chalk; when he clenched his jaw, he felt his teeth break apart in his mouth. The loss of
teeth in dreams is recognised as a sign of anxiety, a fear of ageing and disintegration
(1). With long-term dialysis this nightmare is realised. In waiting for his transplant,
AD described being in a sort of limbo, not knowing whether he would live or die. He
developed close bonds with the other patients undergoing dialysis. This was a source
of support but also constantly reminded him of the seriousness of his condition; he
saw many of them die. He described being given a new life after his kidney
transplant. His account was dramatic, and the experience undoubtedly had a lasting
psychological effect on him.



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DISCUSSION
The patient on dialysis must adapt to their new life; a life that is dependent on a
machine for prolongation, a life that is limited not only by their illness, but by the
regime of dialysis (2). Despite this, patients seem to adapt well initially to their
dialysis treatment. Following a slow decline in renal function over usually many
years, on starting dialysis the patient may feel they are literally and symbolically
rising from the dead. This may lead to a euphoric state in many patients, contributing
to what is described as the honeymoon phase of dialysis (3). However, following
this period, the patient on dialysis may experience a feeling of significant loss: loss of
bodily function, work capacity, earning capacity and sexual performance (4). These
problems may introduce a sense of helplessness, compounded by complications of the
treatment regime, such as clotting at the shunt site or infection (3).

The long-term responses to dialysis can be broadly categorised as regression,
depression and denial (4). Regression represents a reversion to a child-like sick role
in which the person relieves themselves of their usual responsibilities in order to
allow themselves to be healed. This regression is important in order for the patient to
place their care into the hands of another person. However, a patient may find this
regression either too threatening, in which they will resist treatment, or too tempting
in which they will be overly dependent and avoid their responsibilities (5). Dialysis
requires a difficult balance of independence and dependence. During dialysis, the
patient must be dependent on the machine and the medical staff; when not on dialysis
they must be independent and responsible, taking into account dietary and fluid
restrictions for example. Impressively, most renal patients resolve this difficult
dichotomy (4).

Hospitalisation data from ESRD patients showed that the prevalence of depression
and affective disorders was around 20-30% (6-8). The diagnosis of depression in
haemodialysis patients is associated with more hospitalisations of increased duration
(9). However, a relationship between mortality and depression in HD patients has
proved difficult to demonstrate (8, 10). Furthermore, because the kidney is the site of
metabolism for a number of steroid and peptide hormones, a patient with end-stage
renal disease will have higher circulating levels of these hormones (11). Their
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biochemical milieu therefore is similar to a chronic stress response. Therefore, ESRD
may not only cause psychological stress, but also compound physiological stress.

Although it is uncertain what role depression plays in the outcome of end-stage renal
failure, suicide rates for ESRD patients are around 15 times higher that in the general
population (12). Also, around 20% of US dialysis patients voluntarily chose to
discontinue haemodialysis (13, 14). However, whether this amounts to suicide is
controversial and unclear. It has been shown that depression was a predictor of the
decision to withdraw treatment (15). This highlights the importance of identifying and
treating depression in patients on haemodialysis.

Haemodialysis and renal failure can cause many symptoms that disrupt a persons
life. These include tiredness and fatigue, itchiness, muscle cramps and anxiety.
However, it is the patients response to their medical condition and treatment that is
most important to their psychological state (16) - their perceived burden of illness.
This is the patients assessment of how the disease interferes with their personal,
social and occupational lives. It can vary widely depending on the patients age,
gender, cultural beliefs, personality and social support, as well as their understanding
of their condition. The patients burden of illness affects their perception of well-
being, an important component in the assessment of quality of life (17).

Denial is an unconscious coping mechanism that helps defend the patient against the
anxiety-inducing reality of their condition (4). It may be an effective coping
mechanism in both the patient and the family, helping them to maintain optimism and
hope. However, it can become pathological under severe psychological pressures,
with a sudden eruption of the underlying anxiety, possibly culminating in psychosis.

Social support is the perception that an individual is the member of a complex
network that can give and receive affection, aid and obligation (18). It has been linked
to improved outcomes in a wide variety of chronic conditions (18). Familial
relationships can provide indispensable support to a patient with renal failure. A study
has shown the strength of the familial cohesion is related to survival in haemodialysis
patients (19).
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End-stage renal disease is a significant chronic illness and can greatly alter the
dynamics of a marital relationship. The spouse can become the object of the patients
negative emotions, and may have to take up a new role as a caregiver (20). This may
lead to feelings of hostility towards the patient. ESRD may also cause sexual
dysfunction, putting further strain on the relationship. A study on Jewish couples
found that levels of distress were higher in both the dialysis patients and their spouses,
compared to the general population. There was also a strong correlation between the
distress score of the patient and the spouse, implying couples react to disease as a
unit, rather than discrete individuals (20). Social support in the context of dialysis
may take other forms, from dialysis personnel or the other patients on the unit.

CONCLUSION
End-stage renal disease dramatically alters a patients quality of life. The initial
improvement and euphoria is replaced by the stark reality of living with a debilitating
chronic condition and enduring intensive treatment. Unsurprisingly, this has a
profound impact on the individual, with psychological consequences. A solid support
network must be in place to ensure the patient complies and copes with the difficult
treatment regime.

Word Count: 2511

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