R. T. was a 52‐year‐old divorced Caucasian male with end‐stage renal disease (ESRD) due to polycystic kidney disease. He was on thrice weekly hemodialysis for over 15 years until he succumbed to metastatic pulmonary cancer. His average dry weight was 285 pounds. His dialysis course 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 prescribed antihypertensive regimen in spite of severe hypertension.During his years of dialysis, he exhibited both episodic and chronic noncompliance to much of his medical regimen, including: excess interdialytic weight gains of 10–25 pounds. This was a regular chronic noncompliance problem. He constantly drank large amounts of carbonated beverages because, he said, he was thirsty and craved these drinks; frequent high serum potassium predialysis because he refused to follow appropriate dietary regimens; irregular compliance with taking his phosphate‐binders, complaining of severe constipation and often not taking other prescribed medications; occasionally skipping dialysis, offering that he forgot what time it was or that he overslept; factitious dermatitis. Although regularly advised to desist, he picked and scratched on small skin lesions, often producing larger ulcers and abrasions. In fact, this likely led to his early demise. One lesion on his fistula arm was initially thought to be merely a factitious ulcer. However, it failed to heal and enlarged. He was advised to see a surgeon, but repeatedly canceled his appointments. Finally, when biopsied. it was squamous‐cell carcinoma. Despite wide excision and radiation treatments, the lesion metastasized to his lungs and he succumbed fifteen months later.The staff and his physician held repeated conferences in efforts to improve this patient's compliance. Interventions included: admonishment about the risks that could befall him; praise when he did well; frequent counseling by his physician and the staff members he liked; minor rewards such as dialysis time changes or shortening dialysis when Compliance improved; denying his manipulatory behavior and eliciting family support (which was not strong) when appropriate. At times, these interventions were helpful, and he displayed better compliance for short periods. It was noted that he was often depressed and exhibited personality problems. He complained that certain members of the staff didn't like him, and the staff felt antagonized by his noncompliant behavior. His greatest rapport was with his personal nephrologist to whom he responded from time to time with episodic