Dealing with unpleasant patients? Be understanding

Suggestions for unpleasant encounters

Given enough experience and patience, a physician can become adept at dealing with patients who they find noncompliant or overly demanding. But how does a clinician deal with a patient he or she finds utterly intolerable to be around — someone who is abusive, insulting, or completely unlikable?

The first thing the doctor should do, experts agree, is nothing.

"Before you say anything, it is best to try to understand this person rather than simply react," suggests John Banja, PhD, assistant director for health sciences and clinical ethics at Atlanta-based Emory University's Center for Ethics.

Adhering to your role, experts say, rather than reacting to the unpleasant behavior or mannerism, is also important.

"[T]here are specified minimum behaviors that are required in treating every patient in every circumstance. They are the sorts of things that all health professionals do for every patient when acting as care providers," Paul J. Reitemeier, PhD, a member of the National Ethics Committee of the Veterans Health Administration (VHA), explained at a 2001 VHA ethics conference.

Even brief encounters unpleasant

Health care providers usually think patients are "difficult" when they refuse to comply with care recommendations, miss appointments, and are otherwise at odds with their physicians. However, there are those who might be compliant with care but who are verbally or physically abusive, use vulgar or profane language, espouse beliefs morally repugnant to the physician; ignore personal hygiene, or have committed acts or crimes that lead the physician to have a deep, personal dislike of the person.

Developing a dislike for an uncooperative patient seen in a primary care setting or in the course of treating a chronic disease requires the physician to decide how he or she can best work, long term, with that patient, or, in the worst cases, how to arrange for the patient to transfer to another physician.

For a hospitalist or emergency medicine physician, however, encountering an unpleasant, abusive, or otherwise difficult patient means figuring out how best to deal with the patient knowing that this might be the only encounter with that person — in short, how to briefly tolerate an intolerable patient.

The first step, suggests hospital pastoral care director Vincent Guss, MDiv, is to try understanding who the patient is and what might be leading to the behavior.

"If a colleague on the health care team approached me in regard to a patient that person did not like based on their behavior or beliefs, I would suggest that this professional try to discern the interpersonal and intrapersonal dynamics with that [patient]," including cultural and personal elements that might be influencing how the patient is behaving and relating to the health care team, he says.

Then, Guss suggests, "exercise a level of empathy to whatever degree might be possible, balancing that approach with a dispassionate professional commitment to holistic care for the patient's total health and wholeness."

Guss and others readily concede that such understanding and dispassion won't always come easily when a patient is testing a doctor's limits.

Nancy Berlinger, PhD, MDiv, deputy director of The Hastings Center, advises that before addressing what the physician deems noncompliant or difficult behavior, he or she examine those labels.

"Watch out for that word 'noncompliant,'" she says. "As physician and medical anthropologist Arthur Kleinman says, this word implies moral hegemony: I'm right, you're wrong. The provider is the one who is allowed to use it — is it being used to conceal dislike, distrust, or broken-down communications? Is the provider willing to take the time to find out why a patient will not or cannot follow a treatment plan?"

Prompts for communication

Emory's Banja says that when the physician is able to set aside his or her personal feelings about the patient, information might surface that explains the behavior. He suggests asking the following questions to establish some empathy for the patient:

  • "So, this must be very (difficult, sad, frustrating, etc.) for you."
  • "You just said X. Tell me more about that."
  • "So, what you're saying is that..."
  • "Tell me what you've been told so far."
  • "You are obviously very (angry, upset, etc.) — tell me what is happening with you right now."

"If you ask a 'why' question ('Tell me why you are so upset'), follow with a reframing statement, [such as] 'Oh, so you're saying that ...,' and, if appropriate, say, 'Well, no wonder you feel that way,'" Banja adds. "Expressing an observation like, 'Mr. Jones, I have a feeling that you are even (angrier/sadder/more depressed, etc.) than you are letting on' at the right moment can release a floodgate of tears, which is often quite cathartic."

Addressing how the patient must be feeling causes the patient to focus on — rather than feel — the emotion, Banja says, which can calm the patient because it replaces an emotional experience with an intellectual one.

The worst of the worst are still patients

David Schiedermayer, MD, a physician, author, and poet, draws on his experiences as a hospitalist when writing. In "Causing Pain," a poem published in 1996, he described how treating a man accused of rape and murder made him feel:

"So the challenge is
to place the last stitch
like I have many times before
with many apologies
and not enjoy the small pain it causes
in this particular patient."1

While not every physician encounters someone whose actions rise to the level of the patient Schiedermayer describes, most will find themselves treating patients whose behavior or demeanor makes it difficult to stay focused and objective.

Dealing with difficult patient situations is a skill that comes with experience, and Berlinger suggests drawing on coworkers who are good at it.

"Ally yourself with colleagues who are good at preventing or resolving conflicts," she advises. "Physicians can learn a lot from chaplains about how to talk with patients with different beliefs, how to use body language to de-stress a situation — start by uncrossing your arms — and so on."

But Berlinger points out that sometimes, a situation is beyond what a particular physician can or should endure.

Seek help when situation demands it

"You are not ethically obligated to accommodate behaviors and beliefs that are harmful to your patient, other patients, or providers, including yourself," she says. "When a situation goes beyond 'I don't like this patient or his/her beliefs' to 'I think his/her beliefs are putting this patient or others at risk,' it's time to call for an ethics consult."

Despite a clinician's best efforts and intentions, sometimes a patient/physician relationship, no matter how longstanding or brief, needs to end. Berlinger says handling such situations candidly and respectfully, even if the patient is neither, is called for.

When a patient is being "downright nasty," Banja advises telling him or her calmly and without anger, "I hope you will believe me when I say that I and the nurses want to help you. However, when you say things like XXXX, that makes it very hard for us to want to help you."

"Remember that lots of these difficult people are beyond fact and reason," he says. "For some of them, no technique, other than being as polite and as comforting as you can be, will work, and even then, their behavior might persist."

The ethically appropriate response in these cases, says Reitemeier, is "to keep the big picture in mind and become resourceful."

Drawing on intermediaries or hospital resources such as psychiatric or social work consultants can help the provider avoid a situation so deteriorated that the patient receives sub-par treatment.

Guss advises that using the entire multidisciplinary team can assist in getting the patient cared for in spite of his or her repellent behavior, as well as provide a sounding board for the physicians and nurses involved in direct care of the patient.

"Often, this process leads to the quality of compassion and greater empathy, with an increased ability to put oneself in the shoes of the patient," Guss adds.

Cynda Hylton Rushton, PhD, RN, FAAN, an associate professor of nursing who serves as program director for the Baltimore-based Harriet Lane Compassionate Care Program, says the feelings encountered by the physician or nurse might be as much about the clinician as about the patient.

"I would ask, 'What part of my own personal history does this patient/family ignite in me? Is my response to the behavior in proportion to the situation? What behaviors am I noticing in myself or other members of the team in response to this patient? What is the nature of the distress I am experiencing — it is disrespectful behavior, non-adherence, abusive behavior, moral distress?'" she suggests.

"You may not change the person or their behavior, but you certainly can adjust your own response to them. Often we see these types of situations being a huge emotional and spiritual drain on the team and the patient/family. Creating clear boundaries and putting in place an understanding about the norms of acceptable behavior are necessary, coupled with ongoing support for those who are interacting with the person regularly."

And while worst-case scenarios might make transfer of the patient a necessary consideration, abandonment is not an option, Rushton emphasizes.

"There are some — a small number — of cases where these efforts will not resolve the situation and there may be justification for transferring the patient elsewhere if a therapeutic alliance cannot be established," she concedes. "That said, we are not at liberty to abandon patients merely on the basis that we dislike certain behaviors or characteristics."

Reference

  1. Schiedermayer D. House Calls, Rounds, and Healings: A Poetry Casebook Tucson, AZ: Galen Press; 1996.

Sources

For more information:

  • John Banja, PhD, associate professor of clinical ethics; assistant director for health sciences and clinical ethics; Center for Ethics, Emory University, Atlanta, GA. Phone: (404) 712-4804. E-mail: jbanja@emory.edu.
  • Veterans Health Administration National Center for Ethics in Health Care, ethics teleconference, "Managing 'Difficult' or 'Non-Compliant' Patients: Ethical Challenges," Sept. 26, 2001. Transcript available on-line at www.va.gov/ethics/pubs/archives.asp.
  • Nancy Berlinger, PhD, MDiv, deputy director and associate for religious studies, The Hastings Center, Garrison, NY. E-mail: berlingern@thehastingscenter.org.
  • J. Vincent Guss Jr., MDiv, director, pastoral care, Virginia Hospital Center, Arlington, VA.
  • Cynda Hylton Rushton, PhD, RN, FAAN, clinical nurse specialist in ethics, Johns Hopkins Children's Center, Baltimore, MD.