DIFFICULT MANAGEMENT PROBLEMS IN DIALYSIS .2. THE UNCOOPERATIVE PATIENT

R. T. was a 52-year-old divorced caucasian male with end-stage renal d isease (ESRD) due to polycystic kidney disease. He was on thrice weekl y hemodialysis for over 15 years until he succumbed to metastatic pulm onary cancer. His average dry weight was 285 pounds. His dialysis cour se was complicated by late onset diabetes mellitus, severe peripheral neuropathy, and renal bone disease. He had a history of noncompliance, even prior to initiating dialysis, with poor adherence to his prescri bed antihypertensive regimen in spite of severe hypertension. During h is years of dialysis, he exhibited both episodic and chronic noncompli ance to much of his medical regimen, including: excess interdialytic w eight gains of 10-25 pounds. This was a regular chronic noncompliance problem. He constantly drank large amounts of carbonated beverages bec ause, he said, he was thirsty and craved these drinks; frequent high s erum potassium predialysis because he refused to follow appropriate di etary regimens; irregular compliance with taking his phosphate-binders , complaining of severe constipation and often not taking other prescr ibed medications; occasionally skipping dialysis, offering that he for got what time it was or that he overslept, factitious dermatitis. Alth ough regularly advised to desist, he picked and scratched on small ski n lesions, often producing larger ulcers and abrasions. In fact, this likely led to his early demise. One lesion on his fistula arm was init ially thought to be merely a factitious ulcer. However, it failed to h eal and enlarged. He was advised to see a surgeon, but repeatedly canc eled his appointments. Finally, when biopsied, it was squamous-cell ca rcinoma. Despite wide excision and radiation treatments, the lesion me tastasized to his lungs and he succumbed fifteen months later. The sta ff and his physician held repeated conferences in efforts to improve t his patient's compliance. Interventions included: admonishment about t he risks that could befall him; praise when he did well; frequent coun seling by his physician and the staff members he liked; minor rewards such as dialysis time changes or shortening dialysis when compliance i mproved; denying his manipulatory behavior and eliciting family suppor t (which was not strong) when appropriate. At times, these interventio ns were helpful, and he displayed better compliance for short periods. It was noted that he was often depressed and exhibited personality pr oblems. He complained that certain members of the staff didn't like hi m, and the staff felt antagonized by his noncompliant behavior. His gr eatest rapport was with his personal nephrologist to whom he responded from time to time with episodic compliance.