If you believe that coping with some of the people we deal with in emergency medicine is difficult or impossible, you’re not alone. We all feel this way from time to time. Managing difficult patients can be a challenge to the health care provider and to the entire ED.  The hostile aggressive patient, the demanding patient, the know-it-all, the excessively anxious patient, and the incessant complainer, are some of the folks that we need to know how to manage effectively. If we fail to handle these patients appropriately, they may receive suboptimal care, grind patient flow to a halt, and delay care of other patients. If the staff has to deal with a multitude of these patients on a given shift, there’s a sort of swarm-based escalation in frustration and sometimes, unfortunately, a total breakdown of effective patient communication and care.

But don’t fret.  In this one-of-a-kind podcast on effective patient communication and managing difficult patients, Dr. Walter Himmel, Dr. Jean-Pierre Champagne and RN Ann Shook take us through specific strategies, based on both the medical and non-medical literature, on how we can effectively manage these challenging patients. As a bonus, we address the difficult situation of breaking bad news with a simple mnemonic and discuss tips on how to deliver effective discharge instructions to help improve outcomes once your patient leave the ED.

Prepared by Dr. Keerat Grewal & Dr. Anton Helman, Oct 2014

The Dangers of Impaired Communication with Difficult Patients

Impaired communication with difficult patients can lead to a vicious cycle of attacks and counteracts. You may inadvertently direct negative actions towards the patient, who in turn, may feel abandoned. This creates an ongoing cycle of poor communication. Effective communication is vital to breaking this cycle and moving toward solution focused actions.

 

First Line Techniques in Managing Difficult Patients

  1. Gain personal emotional control: Don’t react, be proactive, and know your triggers. Slow down your breathing, speak slowly and quietly, lower your tone, and think about your body language. When feeling frustrated or angry, try reciting to yourself a few times: “I’m alert, I’m alive and I feel good”. Although this may sound someone ridiculous it can be an effective technique in shifting your ‘flight or flight’ amygdala-mediated physiological response to a positive, calm and constructive state of mind.
  2. Start with a good first impression : Smile, use an open posture, introduce yourself, extend your hand for a handshake, look patients in the eye for 3-5 seconds (see Episode 49 on Effective Patient Communication)
  3. Help your patient get emotional control: Don’t argue (arguing will lead to a vicious cycle of attacks and counterattacks as described above). Patients want to feel heard, understood and validated. Say “I’m here to help you and hear you out”.
  4. Effective empathetic listening: Search for the patient’s agenda. Echo or paraphrase what the patient says, and acknowledge their feelings. Say “I can see you are frustrated”.

 

Second-line Techniques for Managing Difficult Patients

  1. Broken record technique: Repeatedly validate the person’s feelings until the situation is diffused. Ask “what is your biggest fear?” or “I can see you are upset” or “I can see why you feel that way” a few times. By the 2nd or 3rd time, the patient will usually shift from being difficult to being co-operative.
  2. Acting “dumb”: When being threatened or attacked, do not fight back; ask clarifying questions to change the attack to clarification. You can say “pardon” or “help me understand what you are saying” or “I don’t understand what you are trying to say”, even though you understand exactly what the patient is saying. Use non-confrontational body language.
  3. Silence: Give the person time to calm down; the person usually burns out within 60-75 seconds

If all else fails…..

Time Out: Take a break from the frustrating encounter if you feel you need it; it is important to take time to identify your own frustrations, anger and countertransferance, think about a game plan before you re-enter the encounter.

 

Reframing and Redirecting

First state yourintent: “I’m here to do what is in your best interest”

Next determine the patient or family member’s interests or agenda. Say “I can see you are concerned; what is your major concern right now?”

Then, ask for their cooperation. Say “I need your help”.

Then, give options…

  • Giving the hostile person options can be a very effective action in diffusing their anger
  • Giving the hostile patient 2 or 3 options changes the focus from argument to action and helps to redirect the patient to a solution focused path

If there is no progress being made with the difficult patient consider saying “This isn’t going well. May we start again?”

Ending the interaction: have a clear plan for action at the end of the interaction. It can be used as a reference if communication were to break down again.

 

The Violent Patient

If you feel your safety is threatened, excuse your self and leave the room.

Get help: either another colleague, or as a last resort, security (do not tell the patient or threaten them that you are getting security as this may escalate the situation).

 

The Anxious Patient

For patients with repeat visits for similar symptoms, resist the urge to label the patient as a ‘frequent flyer’.  Once you have determined that there is no immediate medical problem, it is your job to find their hidden agenda.  An effective way to find out a patient’s hidden agenda is to ask “what’s your biggest fear?”. Once you have shown the patient that you understand their agenda, come up with a plan for further action.

Never criticize the patient’s decision to come to the ED.

For more on how improved physician-doctor relationship can improve patient care read Duncan Cross’s post on the KevinMD blog

 

In the primal sympathy
Which having been must ever be;
In the soothing thoughts that spring
Out of human suffering.
-From Sir William Osler’s History of Medicine book.

 

Breaking Bad News

Bring colleagues who can assist the family (i.e. social work, nursing).

Non-verbal communication strategies: Sit down and establish good eye contact. Use pauses in order to let the family or patient react.

SPIKES Mnemonic for Breaking Bad News

  • Setting: Find a quiet, private place to disclose the bad news
  • Perception: Understand the patient’s perception of what is happening and what the patient already knows
  • Invitation: Get an invitation from the patient to provide the information and determine how much the patient or family wants to know. ”

    Some people prefer a general picture of what’s happened and others prefer knowing all the details. Which would you prefer”

  • Knowledge: A short, relatively quick and concise description of what lead up to the death or illness, followed by a warning (“There is something very important that I am about to tell you”).  Then in a clear and concise manner, tell them the outcome. Use the word dead or death rather than ‘passed away’. Be sure to avoid medical jargon.
  • Emotional Supports: Provide empathic responses and support such as “I can’t imagine how terrible this must be for you” or “this is very difficult news for you”
  • Summarize: summarize what has happened and what will happen next; state a plan of action

A more detailed description of the SPIKES mnemonic.

Disclosing a patient death:

Be direct and gentle, summarize quickly what steps lead to the death. Prepare the patient/family member for bad news “I’m afraid I have some bad news”. Don’t use vague terms. Do not say “I know how you feel” as this might elicit a response such as “You have no idea how I feel”. Consider saying “I’m sorry for your loss”.

Discharge Instructions

Discharge instructions are a very important part of the emergency department record. Ensure patient has an understanding of these instructions5.

Verbal discharge instructions: verbal instructions are more effective than written instructions6-7. Be explicit about instructions. Keep it simple and avoid medical terminology. It may be useful to explain ‘The Uncertainty Principle’ (ie we can never be 100% sure about the diagnosis or the course of illness). Have the patients repeat instructions back to you, to ensure understanding. Ensure patients have a low threshold to return to the ED in uncertain situations. Document this in the chart.

Update 2015: Excellent review of dealing with the difficult patient who wants to leave Against Medical Advice.

Update 2015: Practical framework for managing challenging patient encounters.

Quote of the Month – Mark Twain

“Always do what is right. It will gratify half of mankind and astound the other.”

New York Times article “Can Doctor’s be Taught to Talk to Patients

 

Dr. Helman, Dr. Himmel, RN Shook and Dr. Champagne have no conflicts of interest to declare

 

Key References

  1. Brinkman, R. & Kirschner, R. Dealing with people you can’t stand. New York: McGraw-Hill, In. 1994.
  1. Decker, B. You’ve got to be believed to be heard. New York: St. Martin’s Press. 1991.
  1. Baile, W.F., et al. SPIKES – A six-step protocol for delivering bad news: Application to the patient with cancer. 2000. The Oncologist, 5(4): 302-11. Full text available at: http://theoncologist.alphamedpress.org/content/5/4/302.full
  1. Buckman, R. Breaking bad news: The S-P-I-K-E-S strategy. 2005. Psychosocial Oncology, 2(2): 138-42. Full text available at: http://www.oncologypractice.com/co/journal/articles/0202138.pdf
  1. Isaacman, D.J., et al. Standardized instructions: Do they improve communication of discharge information from the emergency department? 1992. Pediatrics, 89(6): 1204-208. Access to abstract at: http://www.ncbi.nlm.nih.gov/pubmed/1594378
  1. Waisman, Y et al. Do parents understand emergency department discharge instructions? A survey analysis. 2003. Isreal Medical Association Journal, 5(8): 567-70. Access to full text at: http://www.ima.org.il/IMAJ/ViewArticle.aspx?year=2003&month=08&page=567
  1. Engel, K.G. et al. Patient comprehension of emergency department care and instructions: Are patients aware of when they do not understand? 2009. Annals of Emergency Medicine, 53(4): 454-61. Access to abstract at: http://www.ncbi.nlm.nih.gov/pubmed/?term=Patient+Comprehension+of+Emergency+Department+Care+and+Instructions%3A+Are+Patients+Aware+of+When+They+Do+Not+Understand

Questions from ‘Next Time on EM Cases’ by Dr. David Strauss:

How do you deal with patients that accuse you of racism because you do not comply with their requests/demands?

How do you deal with patients that are upset because your care plan does not synch with their fixed delusion or their previous exotic (mis)diagnosis?

Answer from EM Cases’ Dr. Walter Himmel:

The echo technique does not work here. Do not get into a discussion of racism or defend yourself as this changes the encounter’s focus.
Address the person by their full name.  Repeat your name and state that you will do everything possible to help them.  Pause five seconds while using appropriate, non-aggressive body language. Give the patient two or three options (ie give them a choice if possible). State that your intention is to help as much as you can.  Repeat the options.  State again “what I can do for you”.  Identify their feelings without judgement and validate them.

For Part 1-  Episode 49 on Effective Patient Communication

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