Ethicists Become Involved in Managing Aggressive, Violent Patients
Ethicists at the University of Vermont Medical Center are increasingly called on to help clinicians manage verbal and even physical conflicts with patients. “When clinicians try to help aggressive — or, frankly, violent — patients, it pits respect for patient autonomy [against] clinician self-interest and institutional duty to provide a safe work environment,” says Tim Lahey, MD, MMSc, director of clinical ethics.
In response to an uptick in these cases, ethicists created behavior response teams to support clinicians. “The pattern of increasing frequency of consultation led us to conclude there was a preventive ethics interest in developing better plans of response,” Lahey explains. “Either our teams could be more expert at de-escalation, or better at knowing when to say enough was enough.” Ethics could not manage those situations on their own. “We had to catalyze a multidisciplinary collaboration of relevant parties,” Lahey explains.
The behavior response teams resulted from that teamwork, with ethicists playing a major role in collaboration with other hospital leaders. The teams are led by a psychologist working with ethics, security, and other stakeholders. “We devise the right approach to a given patient’s situation. Sometimes, we save the life of a combative patient and put risk mitigation measures in place,” Lahey reports.
An example would be a confused, demented patient with a life-threatening illness who could be sedated; later, a 1:1 security posting could be placed bedside. “We can treat their mortal illness and keep staff safer,” Lahey says.
In some cases, the team notifies a patient his or her behavior is unacceptable. If unchanged, such behavior will lead to loss of non-life-saving care. “When we make boundaries like that, perhaps with a combative patient whose care would ideally happen in the hospital but who ends up being notified their care will be outpatient if they don’t shape up, sometimes they do change their behavior out of self-interest,” Lahey says.
Other times, patients leave the hospital angry. “We hope these preventive ethics interventions help us make wise decisions in the moment while ameliorating the twin risks of bias or clinician physical or moral injury,” Lahey offers.
In situations like these, the nature of the patient-clinician interaction could be contributing to the patient’s behavior.
“Maybe they’re afraid and not expressing it productively. More reassuring communications can help them calm down,” Lahey suggests.
In certain situations, clinicians cannot understand what is driving the patient’s anger. “Clinicians from one cultural background might perceive vehement, emotional behavior on the part of a patient from a different background who has no threatening intent,” Lahey says.
Ethicists can help clarify those cultural differences so patients and clinicians can meet each other halfway. “The chosen multidisciplinary solution differs substantially from case to case depending on the facts behind the worrisome behavior,” Lahey explains.
In some cases, clinicians are turning to behavior contracts, which were typically used to encourage patients to adhere to treatment plans. “Physicians and other staff members sometimes gravitate toward behavior contracts as a means to end destructive interactions or undesirable conduct,” reports Autumn Fiester, PhD, director of the Penn Program in Clinical Conflict Management.
Recently, Fiester co-authored a paper highlighting ethical concerns in the use of behavior contracts.1 “It is understandable that, under very trying circumstances, providers reach for this tool. But in my view, behavior contracts are not ethically justifiable,” Fiester says.
Behavior contracts can be effective in stopping disruptive behavior. “Patients in need of care may modulate their behavior in order to safeguard their ability to access the care they need. But that doesn’t make the tool ethical,” Fiester says.
Behavior contracts might simply coerce patient or family compliance without solving the conflict’s cause. The ethical concern is the potential damage inflicted on the doctor-patient relationship and in the trust in the institution. Instead of using behavior contracts, Fiester suggests healthcare systems focus on providing effective skills to manage interpersonal conflict. “Mediators and conflict management experts have tools to enable providers to prevent conflicts from occurring and to troubleshoot them when they do,” Fiester says.
Healthcare institutions can identify staff members who already possess this expertise, or train staff with the potential to function as mediators in these circumstances. “Those techniques get to the root of the conflict so they can be solved at their source,” Fiester explains.
- Fiester A, Yuan C. Ethical issues in using behavior contracts to manage the “difficult” patient and family. Am J Bioeth 2021;Sep 30:1-11.
A facility in Vermont created behavior response teams, with ethicists playing a major role in collaboration with other hospital leaders, a psychologist, security staff, and other stakeholders to better manage volatile situations and protect the well-being of patients and employees.
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