**2. Psychosocial issues in the transition to hemodialysis**

The actual transition from chronic renal care to hemodialysis therapy results in a new challenge for patients' lives across all aspects [2]. This transition period is critical and associated with many psychological stressors. Future uncertainty, being a burden on family, financial strain, transportation issues, physical dysfunction, lifestyle and schedule changes, and travel restrictions are all sources of psychological stressors. In fact, many patients experience shock when they are told to start dialysis [3]. This initial shock event can lead to a serious psychological crisis. The patient may experience denial, regret, depression, anxiety, worry, anger, sleep disturbances, grief, and isolation [4]. Moreover, newly commenced dialysis patients may experience identity alterations because of altered body image, dependence, frailty, and loss of identity [5]. During the initial hemodialysis, patients often deny the fact that dialysis has become part of their lives and is a permanent treatment [6]. Denial is regarded as a protective mechanism for dealing with emotional stressors associated with dialysis [7]. Denial may lead to a refusal to adhere to dietary and fluid restrictions and a testing of what happens when they break boundaries. In some cases, this may lead to withdrawal or decreased compliance with dialysis [7]. A previous study reported a correlation between withdrawal and early dialysis initiation [8]. The first year on hemodialysis is a central period for adaptation and coping [5]. Perhaps it is only a matter of time before the patient accepts the fact that dialysis is sustaining their life. Indeed, when patients' health deteriorated significantly, they eventually accepted the reality of dialysis and followed the instructions.

In a qualitative study that explored patient experience after the first year of dialysis, family and dialysis acceptance and coping were the dominant psychosocial stressors [2, 5]. Patients feel that hemodialysis affects social interaction and changes their relationships. Furthermore, physical and psychosocial functions affect their ability to work and be independent. Studies show that the first years of initiating hemodialysis are associated with changes in employment status and reduce the income [9, 10]. Given this, depression and social isolation may become apparent until the patient accepts and adapts to the new treatment [5].

Transitioning from other treatment modalities, such as peritoneal dialysis, to hemodialysis is required in some cases. This transition also imposes some psychological issues [11]. Patients are frequently hesitant to accept or change a treatment at first [11]. These patients may also experience similar psychological issues (e.g., depression, fear, and anxiety) as patients who have been transferred from pre-dialysis care to hemodialysis for the first time.

#### **2.1 Psychosocial care in the initial period of hemodialysis**

Assessment of psychological status should be an integral part of hemodialysis care, especially during the transition period. To facilitate a healthy transition to hemodialysis, clinicians should be alert during this critical period for any changes in

#### *Psychosocial Aspects in Hemodialysis DOI: http://dx.doi.org/10.5772/intechopen.109592*

emotion and mood and provide social and emotional support [2]. A patient-centered approach of care should be applied through individual evaluation of each patient to meet his or her supporting needs. It is critical to provide effective training and educational programs for patients and their families in order to improve acceptance and coping with hemodialysis. Moreover, providing opportunity to share experience and talking to other patients on dialysis will help in this regard.

New patients may be reluctant to ask questions or express their feelings. Establishing a trust relationship between patients and healthcare professionals improves the patient experience and facilitates coping mechanisms [5]. This relationship will enable information sharing, promote self-efficacy and management, support decision-making, and reduce depression and anxiety.
