Reluctance to accept life-saving treatment.

The patient is a twenty-three-year-old man with end-stage kidney disease who has major conflicts about receiving maintenance hemodialytic treatment. These conflicts stem in part from the patient's hospitalization at the age of seven and the witnessing of heroic medical procedures used in an attempt to treat his father's eventually successful suicide. His unconscious doubts of his manliness result in a pseudoindependent behavior and a pose of hypermasculinity which induce a rejection of passivity and the dependent position necessitated by being a patient on hemodialysis. Rejection of hemodialysis may be a conscious or unconscious suicide attempt. In this patient, it may be a consequence of guilt in relation to his father's death and of other psycho-social factors. Effective treatment for this patient should include allowing him to exercise his independence in as many ways as is possible. Home dialysis and renal transplantation lend themselves to greater feelings of independence and may be preferable to center hemodialysis in this patient. The feelings surrounding the death of his father should be explored with a liaison physician or psychiatrist.