Objectives: Unplanned dialysis initiation is associated with higher mortality and morbidity than elective dialysis starts. Among patients who underwent emergent hemodialysis (HD) initiation, we aimed to determine patient-reported factors influencing initial decision against elective dialysis initiation. To identify gaps in current peri-dialysis education, we studied changes in patients’ perspectives pre- and post-HD initiation Methods: We conducted interviews using survey questionnaires from August 2020 to July 2021 in 32 HD patients at outpatient nephrology clinics at National University Hospital (NUH) Singapore. The study population included End-Stage Kidney Disease (ESKD) patients more than 21 years old who initiated dialysis without an existing dialysis access from June 2019 to May 2020. We excluded patients who lacked mental capacity, had delayed access creation from system factors, or who required interim dialysis while awaiting kidney transplantation. Results: Majority of our study population were males (n=23, 72%) and of Malay ethnicity (n=14, 44%). The most common patient-reported factor for initial dialysis refusal was financial concern (n=30, 94%), followed by concerns over lower quality of life (n=26, 81%), fear of dialysis making overseas travel challenging (n=23, 72%), fear of undergoing surgery for access creation (n=23, 72%), and fear of dialysis dependence (n=22, 69%). Factors convincing patients to initiate urgent start dialysis included doctor’s recommendations (n=28, 88%), worsening symptoms from progression of kidney disease (n=22, 69%), family and social support (n=13, 40%). Study participants felt that listening to experiences from dialysis patients (n=19, 59%) and in-person viewing of the dialysis centre (n=17, 53%) would have helped convince them for elective dialysis initiation. Conclusions: Our study identifies gaps in current pre-dialysis counselling as identified by patients. There is need for change in today’s peri-dialysis education strategies to increase uptake of elective dialysis initiation. We propose involving family in decision-making, arranging dialysis centre visits, catering pre-dialysis education to individual needs as potential strategies.