Levy, N. B., ed. LIVING OR DYING: ADAPTATION TO HEMODIALYSIS. Springfield, III.: Charles C Thomas, Publisher, 1974. 145 pp.. $10.75.
Recent advances in medical technology have posed unique challenges to modern man's adaptability and to his code of ethical behavior. One such challenge has been created by renal dialysis, a life-sustaining procedure for victims of chronic kidney disease. For an estimated 20,000 people, hemodialysis will become a way of life and not simply a stepping stone to kidney transplantation. The types of stress that impinge on this way of life are without precedent. Because dialysis is costly, resources are limited and patients must be selected who will adapt favorably. Once selected, the future dialysand must learn to depend on a lifesustaining apparatus and on the people who operate it. And if he finds the quality of his life unacceptable, he risks the harsh disapproval of his family and dialysis team should he choose to terminate treatment. Under such circumstances it is remarkable that most patients meet these challenges and achieve an existence that is satisfying to themselves and their families.
This small volume consists of the proceedings of a panel of investigators convened at the 125th annual meeting (1972) of the American Psychiatric Association. All have made contributions to the study of adaptation to dialysis. The book includes a series of preliminary investigations. Most deal with small numbers of patients and offer impressionistic conclusions. The authors begin by drawing attention to the vulnerability of this group of patients by citing the high incidence of suicide that has been established for them. Additional problems pointing to adaptive failure are loss of selfesteem and morale, failure to return to work, lack of cooperation with the dialysis regimen, chronic weakness and fatigue, and deterioration in sexual function.
The central problem to which the authors repeatedly return is that of dependency. They note that a disturbing disparity often exists between the expectations placed upon a dialysis patient and his ability to return to roles of responsibility and productivity. Several point out that this dependency may have a poorly recognized physiologic basis. Dialysis patients remain anemic and weak. Many are easily fatigued and suffer losses of potency. Among those who are dependent before becoming uremic, dialysis offers comforts and gratifications for the sick that are difficult to part with. For the overly independent person, dialysis brings a crippling loss of autonomy. This person's rebellion against the curtailment of his freedom may take the form of dietary indiscretions and improper shunt care.
The effect of the attitudes and expectations of families and dialysis teams on dependencyrelated problems is underscored by these authors. Many, looking for grateful and cooperative patients, find instead expressions of dissatisfaction or resentment that are difficult to accept. Others expect complete restoration of function and are intolerant of chronic illness. In these circumstances, the dialysis patient experiences a fall in his sense of worth and a decline in morale. He grows vumerable to me opinions and approval of others but must inhibit expressions of resentment lest he invite rejection and endanger his life. The ultimate deterioration of this tenuous interpersonal atmosphere occurs when a patient decides to discontinue dialysis. Since many families and dialysis teams view such a choice as unthinkable, the patient finds himself quite alone in his decision.
Hemodialysis opens a rich field for the further study of adaptive mechanisms. The work is just beginning. The importance for members of the dialysis team of understanding the emotional problems encountered by dialysis patients is already clear. The need for psychiatric consultation on dialysis units is also clear. Significant questions regarding the ethical principles to be followed in meeting our obligation to these patients will continue to be debated. This book is an early contribution to what will be an ever-increasing literature on this and related topics.