DIFFICULT MANAGEMENT PROBLEMS IN DIALYSIS .2. THE UNCOOPERATIVE PATIENT

A 43-year-old white, single man, who lives with his parents and has be en diabetic since the age of 14, has been on center hemodialysis since January, 1990. He worked as an electrician, but because of medical co mplications connected with his diabetes, he has been permanently disab led since 1986. He failed self-care dialysis due to major errors in ju dgment which could potentially have been life-threatening to him. On c enter dialysis, he skips treatments on occasion and has interdialytic weight gains averaging 4-8 kg. About once a week he cuts treatment sho rt because of leg cramping and/or arguments with nurses. He demands Xa nax while being treated and, if the nurses are reluctant to give him t his medication, he cuts the treatment short. On two occasions, he has received emergency dialysis because he skipped three consecutive dialy ses. In the past three months the situation has deteriorated further. His weight gains have increased and he cuts dialysis short more freque ntly. For the past two months, when he comes to dialysis, he takes out a knife and places it on his bedside stand. He has never threatened a nyone, but the nurses feel a bit compromised by it. His family has kep t themselves very separate from the treatment. He speaks highly of his parents, who, although elderly, are apparently in good health. They a re rarely in contact with the dialysis staff. When the social worker h as attempted to contact them, they have communicated a lack of interes t in being involved with the ''problems of the dialysis unit.'' Needle ss to say, the staff finds the patient's behavior and the attitude of his parents a major problem. He is very impulse-ridden, has little abi lity to tolerate frustration, and, worst of all, denies any responsibi lity for his actions or inactions. He complains of an unsatisfactory d ialysis schedule and of the nurses being angry with him. He denies sui cidal thoughts, but admits to being depressed and feeling hopeless.