**6. Conclusion**

78 Technical Problems in Patients on Hemodialysis

In the nephrology area, there are reports of better QOL and less depression among dialysis patients with greater perception of spirituality and religiosity (Patel et al., 2002; Finkelstein et al., 2007). People identified as spiritual report better social support (Patel et al., 2002). Cumulative positive effects of social support and spirituality can explain lower mortality and better well-being (Spinale et al., 2008). Nevertheless, more studies on spirituality are necessary among HD patients. But it is promising that spirituality and social support could be targets of intervention. Strategies aiming at engaging patients in discussions about their spiritual concerns together with planning activities to involve patients' social support

Coping style: Common sense as well as scientific evidence shows that the way people face difficult situations is the main measure of the effects of stress in their lives. This explains why in clinical practice there are patients with many handicaps who still perceive their lives as pleasant, while others with fewer problems do not. This is also the basis of the importance of all subjective measures discussed here. Coping tests are simple and can be used by dialysis stuff without psychologists' help. Moreover, coping style is a modifiable variable, which can be changed by adaptation training programs. My study team found a correlation between emotion-oriented coping and poor QOL regarding the physical (physical functioning and role-physical) and mental (role-emotional and mental health) dimensions of the SF-36, in line with other studies of chronic disease patients, including the ESRD (Bombardier et al., 1990; Wahl et al., 1999; Dunn et al., 1994). In my view, coping is a potent measure and can be a suitable target for interventions to improve QOL. This personal

When thinking about how to improve QOL among HD patients, two facts must be considered. First, despite a great number of studies, there are no recommendations possible based on Level I or II evidence (Madhan, 2010). The reason is that while there are many cross-sectional studies of QOL, there is a lack of interventional and randomized controlled trials. Second, there has been no improvement of QOL among dialysis patients in the past decade (Gabbay et al., 2010). Recent technical advances and treatment guidelines have not been associated with changes in QOL, although a study of a small sample showed it was possible to improve QOL associated with better quality-of-care indicators (Lacson et al., 2009). Thus, targeting the current quality-of-care indicators concerning anemia, nutrition, dialysis dose, phosphorus level and vascular access must be the first step. These indicators are well known by clinicians. But this first step is not enough. Dialysis associated stressors are powerful. So what else can be done? Faced with a lack of adequate evidence, opinion is what determines efforts to improve QOL. As an assistant nephrologist, medical professor and researcher on QOL and correlators, I suggest, based on my study results, that physiotherapeutic approaches along with psychological interventions can minimize the

Dialysis patients have very low physical domains of QOL compared to healthy people. On the other hand, mental aspects are the same or even higher than in the general population (Perneger et al., 2003; Kusek et al., 2002). In my experience, the dimension role-physical (from the SF-36) consistently presents the lowest score among HD patients. Questions which generate role-physical score are related to difficulties in work and other daily activities

networks in treatment problems could improve subjective and objective outcomes.

view is addressed in more detail in the next section.

effects of dialysis on patients' well-being.

**5. How to improve well-being among hemodialysis patients** 

Well-being is a main outcome in treatment of ESRD patients with dialysis. However, scientific evidence is lacking about interventions to improve well-being. The best way of assessing patients' well-being is to estimate the QOL level using validated instruments. Over the last decade neither technical advances nor quality-of-care guidelines have been enough to improve QOL among HD patients. Emerging knowledge about subjective measures associated with QOL can be the key for effective interventions. Clinicians must be familiar with subjective measures and use them in their daily practice to try to improve the well-being of patients undergoing HD. After 50 years of the widespread of dialysis treatment, the improvement of QOL among dialysis patients remains a formidable challenge.
