Laugh Out Loud Hemodialysis (LOL-HD): Improving the Dialysis Experience at Satellite Healthcare

This blog post was made by Paul Bennett on April 18, 2019.
Laugh Out Loud Hemodialysis (LOL-HD): Improving the Dialysis Experience at Satellite Healthcare

Laughing as a group while you are on dialysis sounds a little strange. How can you pretend to laugh? How can you laugh when you have pain, are tired and stuck to a machine for 4 hours? Maybe we want to turn the question around and ask ourselves “Why not laugh?”

Dialysis staff will say to me “we have a laugh at work and we try to make the patients happy” and patients say to me “the staff are very friendly and some of them are very funny”. This is brilliant and reflects a great center culture. In saying that Laugh Out Loud Hemodialysis (LOL-HD) takes this even further.

LOL-HD is based on Laughter Yoga, which combines deep breathing, stretching exercises, and laughter exercises. LOL-HD is intentional group laughter led by laughter therapists. The sessions go for approximately 30 minutes while patients are sitting undergoing hemodialysis. Trained laughter therapists lead staff and patients through about 12 to 15 exercises that encourages intentional laughter. Describing it in text is pretty much impossible so if you want to know what this looks like click on this link


We all feel better when we laugh—but there is also science behind laughter. Let’s start with the most obvious benefit: an improvement in mood. Laughter can increase the production of the happy hormones “dopamine, endorphin, oxytocin and serotonin” resulting in decreased long term heart rate and blood pressure all the way to a euphoric state. This improved mood and decreased anxiety has even been demonstrated in dialysis.1

Furthermore, increases in endorphin has resulted in improvement in pain threshold. We also know this from studies in childbirth where mothers can deal with incredible pain levels because of increased endorphin production. Therefore, people who laugh more can decrease their chronic pain levels2 which is highly important in a country like the US where 60% of all dialysis patients have at least one opioid prescription for pain per year.3

There are breathing and lung benefits. Nature has provided us with muscles of breathing in (inhalation via the diaphragm & intercostal muscles), but there are no muscles of breathing out (exhalation) which is passive. Our lungs are elastic organs and they expand with deep inhalation. Exhalation on the other hand takes place by the elastic recoil of the lungs, which brings them to the normal resting position. Therefore, to force exhale the respiratory reserve (and clear the lungs), we need to use the abdominal muscles to squeeze out the residual air from the lungs. Laughter encourages people to exhale double the amount of air than they inhale. This is where laughter exercises really help, as it is a great way of expelling the expiratory reserve air from the lungs. Prolonged laughter is like forced exhalation and as we now can help remove lung secretions.4 Most of us have laughed and coughed – this is what laughing does. Therefore, we ask people to laugh as long as possible.


Science also tells us that laughter can improve blood vessel and heart function through increased heart volume output5, decreased blood vessel stiffness6, lower rates of heart attack7 and improved blood lipid and cholesterol profiles.8

Really interestingly, when we laugh for long periods of time, we can increase our immune response by increasing the production of what we call “Natural Killer” cells.9 These natural killer cells are like in-body surveyors who continually roam around our bodies looking for invading bacteria, abnormal viral cells and tumor cells.

What does this have to do with home dialysis? Let’s just start with the point that the most success has been seen with group laughter, such as a dialysis center. In saying that, we can feel isolated at home with many people unaware of the challenges we face in doing home dialysis. That is why it is even more important to look after ourselves, which includes as much laughter as possible. For those wanting to know more, simply google “Laughter Club” or “Laughter Yoga” in your area. Laughter clubs are everywhere in the world and they can change our way of thinking about laughter as a therapeutic tool.

LOL-HD is a full laughter workout, both physically and mentally!

LOL-D in action
LOL-D in action. Image: Copyright of Satellite Healthcare
Laughter Infographic
Laughter Infographic: Copyright of Satellite Healthcare


  1. 1. Bennett PN, Parsons T, Ben-Moshe Rea. Intradialytic Laughter Yoga therapy for haemodialysis patients: a pre-post intervention feasibility study. . BMC complementary and alternative medicine. 2015;15(1):176.

  2. 2. Dunbar RIM, Baron R, Frangou A, et al. Social laughter is correlated with an elevated pain threshold. Proceedings of the Royal Society B: Biological Sciences. 2012;279(1731):1161-1167.

  3. 3. Kimmel PL, Fwu C-W, Abbott KC, Eggers AW, Kline PP, Eggers PW. Opioid prescription, morbidity, and mortality in United States dialysis patients. Journal of the American Society of Nephrology. 2017;28(12):3658-3670.

  4. 4. Leibovitz Z. Humour and dialysis. EDTNA ERCA J. 1998;24(4):17-18.

  5. 5. Boone T, Hansen S, Erlandson A. Cardiovascular responses to laughter: a pilot project. Applied Nursing Research. 2000;13(4):204-208.

  6. 6. Xaplanteris P, Vlachopoulos C, Baou K, et al. Divergent effects of laughter and mental stress on aortic stiffness and wave reflections. Paper presented at: EUROPEAN HEART JOURNAL2007.

  7. 7. Berk LS, Tan SA, Berk D. Cortisol and Catecholamine stress hormone decrease is associated with the behavior of perceptual anticipation of mirthful laughter. In: Federation of American Societies for Experimental Biology; 2008.

  8. 8. Sharma V. Beneficial effect of laughter yoga and clapping exercise in coronary heart disease (CHD) patients in south Delhi metro population. Atherosclerosis. 2018;275.

  9. 9. Bennett M, Zeller J, Rosenberg L, McCann J. The effect of mirthful laughter on stress and natural killer cell activity. Alternative therapies in health and medicine. 2003;9(2):38-45.


  • Francesca Tentori

    Apr 19, 2019 11:34 PM

    I am nephrologist and researcher, and I work for DaVita.
    Your comment struck me because the experience you describe is exactly what we don’t want. With “we” I mean the great majority of professionals across the dialysis industry, from patient care technicians to Chief Medical Officers; however, this response only reflects my own opinions. In my mind, the goal is to provide care that makes every patient feel safe, respected and cared for. That’s what’s important to me when I take my daughters to a doctor, and what patients with kidney disease have expressed over and over. Finding ways to deliver that type of care to a large number of dialysis patients is one of the most fulfilling parts of my job. Your experience clearly indicates that there is so much more to be done. The first step is to understand the patients’ experience and point of view, and I am grateful you were willing to share yours. Please keep the conversation going!
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  • JoAnn Soyka

    Apr 19, 2019 4:35 AM

    You can forget about doing anything that humane at a Davita dialysis clinic. They are all about dragging in patients, stripping them of their humanity for 3 or 4 hours, then getting them out and getting their chair ready for the next paying customer.
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    • deborah

      May 28, 2019 7:58 PM

      you are EXACTLY right. As a patient blows my mind the way they hoard people in and rush them
      ...this is why I perform dialysis at a hospital that manages their own dialysis clinic. It is imperative to treat patients humanely. While the private dialysis companies pretend that patient satisfaction is their goal? they make this impossible to provide. scheduling is done by the administration staff who are trying to keep everything under a budget. their bonuses rely on them. lately though, our administration has been pushing the same things these places days are numbered in dialysis. I hate this mentality and want no part of it.
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    • John Agar

      Apr 19, 2019 11:51 AM

      JoAnn ...

      Maybe they just haven’t thought of it.

      While my experience tells me that the company providers do seem to cop a lot of flack from their users ... and I don’t profess to know enough detail about US dialysis delivery at ‘point-of-service’ to know how widespread and/or deserved this is [though the repeated nature and vehemence of individual comments suggest ‘they’ do not do dialysis well ‘over there’] ... I am told some of them do read, and monitor, sites like this.

      If so, then maybe blog like Paul’s laughter blog, or our now long distant U3A report for 1991, may trigger low cost, high benefit discussion in the DaVita, Fresenius, and ‘other’ company Board Rooms ... sufficient to change the landscapes of future services.

      You, and I, can but hope ......
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  • John Agar

    Apr 19, 2019 1:14 AM

    Paul ... this is one of the best blogs this site has ever put up. It is well researched, well written, and most of all, well targeted.

    It is such a simple concept, yet so crucial.

    It puts me into in mind of some work we did, many years ago, where, in 1991, Rosemary Heintz and I presented a paper at the Renal Society of Australasia - as an renown Australian dialysis nurse, you were likely there and may even remember it.

    It was ... Heintz RA, Simmonds RE, Agar JWM. Dispel the Dialysis Doldrums. RSA Abstracts. Renal Society of Australasia. Adelaide, July 1991.

    We reported the marked mood upswing, engagement and enthusiasm we found when we used in-dialysis hours to have a University of the 3rd Age lecturer [these are primarily retired teachers and academics] come in to the unit during each dialysis session and run a ‘course’ with our patients. He focused on genealogy, local history, and precursor of the now popular ‘where did I come from’ TV series.

    While not a LOL-HD program like yours, It was nevertheless interesting stuff, and draws some parallels to the LOL-HD concept. Like you point out with LOL-HD, our patients - too - became so enthusiastic that they did their went off after dialysis to do their own research on their ‘off-dialysis days’, bringing it back to the next session and - with his leadership - presenting whatey had discovered to others during the next session. Dialysis time flew by ....

    It was growing, organically, into a wonderful and inspiring program until, after a little over 12 months, a serious motor accident forced our guru to stop. We never found a replacement - but should have looked harder. At the time, I had moved on the other interests, and the program ceased. But I have carried the guilt of allowing that to happen ever since.

    The LOL-HD concept seems, in many ways, to be similar. It is all about using the on-dialysis hours to enrich, to engage, to uplift, and to be respectful ... whether through the clear psychological and physiological benefits of laughter - a ‘no-brainer’ of an idea - or through the mental stimulus and curiosity of education - ‘use-brainer’ concept.

    It should be so simple to set up. Maybe someone who reads your blog will take it forward ... I certainly hope so.

    It puts me in mind of the Robin Williams film where he so admirably portrayed Dr Hunter ‘Patch’ Adams, bringing joy into the lives of sick children. A film worth re-visiting in the light of this blog ... and re-working within out dialysis population.

    Wouldn’t it be beaut of CMS funded each dialysis unit for 4 x 2 hr sessions a week ... one per shift per week ... to bring in ‘happiness specialists’ to help our patients pass their on-dialysis hours ... and, who knows, patients may even be prepared to stay on a bit longer = to their absolute benefit, too.
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