Handling difficult patients requires careful policy

Issue impacts employee safety, discrimination

Recently, In-Home Health’s Mesa, AZ, office took on a patient who initially caused no problems. As time progressed, nurses reported more and more problems, not with the patient, but with his wife.

"Nurses and nurses’ aides were telling me that she was being mean," recalls Teri Clark, RN, BSN, visit division manager.

After several such complaints, Clark went to the patient’s home to assess the situation.

"I’ve gone out before to try to settle down cranky patients, but this was the wife. We didn’t talk specifically about anything, but about her concerns. I think it did her good to see that the boss was coming out. She wanted to know that her husband was something more than a number."

Just having Clark go out was enough to solve the problem, and there hasn’t been a complaint about that client since. This is one of the easier instances of difficult patients and family members that home care agencies face. Handling these situations requires a clear policy on how to deal with problems while staying within the confines of the law.

Take an instance where a patient requests the agency only send white nurses to the home. Crestview Hills, KY, attorney John Gilliland notes that just as you can’t refuse a patient based on race, you can’t honor a request for a caregiver to be a certain race or gender.

"The only exception to that is a gender pre-ference when the care provided involves the patient’s sexual privacy, bathing of genital area, for instance. Otherwise, you can’t honor preferences."

Gilliland says a racial preference by the patient is grounds for discharge. "If you were to honor that request, you risk a suit of racial discrimination for the employee, even if the employee has other work. Separate but equal is not the law of the land. You can also lose your Medicare certification for doing this."

Cathy Neilsen, RN, CPHQ, vice president of clinical services at In-Home Health in Minnetonka, MN, says their policy is to tell such patients that In-Home Health will send a qualified caregiver. In such instances, she has to also be concerned with employee safety — particularly if a nurse goes in who is not of the patient’s stated racial preference.

"Before I would send a caregiver to that situation, I would do a personal assessment. You have to err on the side of employee safety."

Safety issues are also a concern when there are abusive patients. Neilsen recalls one instance where a male client was physically abusive to two female aides. "Then we sent a male aide and he was just as abusive. Then it’s a discharge issue."

Clark says she has had two occurrences of patients who have sexually harassed staff. In one case, a quadriplegic patient made statements that upset an aide who was bathing the patient and had to put a condom catheter on him.

"She finished her care and reported the incident to us," says Clark. "We talked to the social worker who visited the patient with the case manager and made it clear that any more of that kind of behavior would lead to discharge. It worked. There were no more problems."

Gilliland deals with issues surrounding difficult patients several times a year. "The problem is to avoid patient abandonment," he says. "That becomes an issue of reasonable notice.’ But there is no clear definition of what that is."

When you have to terminate

Gilliland asks his clients two questions to determine whether there is a case for abandonment:

How long will it take to find another agency? The time may be dependent on your market (less time in an urban area than rural), the kind of care the patient needs, or the "difficulty" that leads you to want out of the relationship.

"There is no specific amount of notice," he says. "It depends on the case. You need to give reasonable notice, and that changes." In a rural area, a ventilator-dependent patient is going to need more notice — maybe a couple of weeks," Gilliland says. "If the care is not life threatening for a weekly visit patient, then maybe you can terminate today because they have time to find another provider."

What happens if they don’t get another provider? A little discomfort isn’t a problem, but hospitalization or death is cause for concern.

Gilliland asks his clients to document this and pick a date to terminate care. Then, in writing, confirm to the patient and/or the family the termination date, the reason, the agency’s willingness to assist with continuity of care and to brief a new agency, and the names and numbers of agencies the patient or family can call.

"Then stick to your deadline," says Gilliland. Often, patients won’t believe you are leaving until the nurse doesn’t show up. "That’s really hard on nurses, because they are caring by nature. Patients will often try to manipulate nurses to keep them there. You have to stick to your guns."Send a copy of the letter to the physician, he adds.

All terminations should be done in line with your discharge policies.

"Remember those policies should be broad enough to take into account uncooperative and harassing patients. Make sure the policy covers whatever issue you are talking about," says Gilliland. If that policy has in it a minimum notice for termination, then unless it is a case where safety is an issue, then you need to stick to that policy.

While Gilliland notes that you can’t share patient information without that patient’s consent, often the incidents which led to termination are reflected in chart notes.

"If you get a call to admit a patient and the other agency won’t say why they discharged him or her, then that should be a big red flag to you."

In-Home Health’s policy on discharge also includes a referral to adult protective services in cases where termination is immediate due to issues of employee safety, to ensure continuity of care.

Communication is key

A good policy for dealing with difficult patients, says Clark, will include the following elements:

A chain of discussion. The employee tells his or her supervisor, who pulls together a care conference which includes the family or caregiver if appropriate. The physician is also notified about the problem, not just because termination could impede care, but because the physician might be able to help in dealing with the difficult patient.

A method of conveying behavior dissatisfaction to the patient. This should include verbal and written methods. In-Home Health uses a case manager or social worker for the verbal presentation.

Clark adds that a good policy must make it clear to staff that they can report an incident and action will be taken.

"We have no way of finding out about problems other than from our staff," she says. "They have to know there is an open door policy."

Agencies wanting to develop a good policy may want to use their ethics committee to formulate one, since so many of the issues surrounding difficult patients bleed into issues of abandonment and patient discharge, Clark adds.

If you have a corporate office, she suggests that you bounce ideas off of appropriate executives at the corporate level, and make use of its legal department to ensure your policy is within the bounds of the law. If you don’t have a corporate entity, you should talk to peers and colleagues in your area.

Finally, don’t imagine you can think of all the potential issues that may arise, warns Clark. She recalls one instance where a patient was espousing religious beliefs that the employee found disturbing and offensive. Eventually, she was able to broker an agreement that maintained care by having the patient promise not to bring up the topic again.


John Gilliland, JD, Law Offices of John Gilliland, Crestview Hills, KY. Telephone: (606) 344-8515.

Teri Clark, RN, BSN, visit division manager, In-Home Health, Mesa, AZ. Telephone (602) 962-4923.

Cathy Neilsen, RN, CPHQ, vice president, Clinical Service, In-Home Health, Minnetonka, MN. Telephone: (612) 449-7654.