The prolongation of life by artificial means is a compelling topic for the physician who treats patients with chronic hemodialysis. This paper discusses the stresses, losses, and restrictions which dialysis imposes upon the patient, his family, and other caretakers. Examples of psychological reactions to such circumstances are given and major conflictual problems are described. The role of dependency and independence in chronic illness, the use of denial as a major defense mechanism, alterations in body image, attitudes towards life and death are all discussed in terms of the psychological reactions to the stress of hemodialysis. The problem of suicide is illustrated with a variety of forms it takes in these special patients who depend upon mechanical devices for their very existence. Some of the moral, ethical and economic problems of patient selection for hemodialysis are indicated and briefly examined.
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