When a chronic illness becomes terminal.

Patients with ESRD and their families experience a variety of transitions across the trajectory of this chronic illness. A major transition occurs when patients who have been perceived as chronically ill become terminally ill, as changes and complications limit options for treatment. These changes are very disruptive, characterized by uncertainty and disturbances in the patients' prior view of themselves. In order to restructure a new reality, patients must acknowledge the losses and changes that have occurred. Several kinds of trigger events may facilitate this process. Patient responses to the transition include a variety of strategies such as seeking information, normalizing, comparing themselves to others, and finding their identity in continuing activities or substitutes that make them feel competent. Nephrology nurses knowledgeable about this transition process, because of their longstanding relationships with ESRD patients and their families, are in an excellent position to take advantage of opportunities to provide presence, understanding, and guidance in negotiating this difficult transition.