Dealing with difficult patients

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General principles for dealing with difficult patients who are cognitively intact

As caregivers, we often find ourselves extending ourselves for our patients, “going the extra mile”. This works well when the patient is appreciative of our efforts: we feel good about ourselves. But if our efforts are not appreciated, we are less likely to feel good. And if the patient behaves as if he or she is owed that effort, we may begin to feel abused. When we feel abused, it is normal to get angry.

In fact, it is normal to get angry whenever somebody or something hurts or frightens us. Anger, like other emotions, arises spontaneously and instantly, and is not under our conscious control. Anger was built in by evolution because it allows a species to survive. It gives us the courage and energy necessary to overcome obstacles. Imagine what would happen if a mother does not have the capacity to get angry when, for example, a wild animal carries off her child!

Again like other emotions, anger is a stimulus for action. Anger, the emotion, leads to angry behaviour.

While anger at abusive patients is a perfectly normal emotion, and appropriate to the situation, angry behaviour on our part towards our patients is not acceptable. The problem here is that we may not be aware of our anger, and thus fail to see our behaviour towards the patient as angry behaviour.

Angry behaviour by caregivers can take many forms: being slow to respond to a call bell; failure to greet the patient appropriately; giving care without asking for consent; being rougher than we might otherwise be. Our tone of voice and choice of words can also be manifestations of angry behaviour.

So how can we control our angry behaviour? Self-control improves with maturity and practice. But the reality is that angry behaviour is really very difficult to control. The reason for this can be found in what is called the “fight or flight response” to a threat.

The fight or flight response is a series of physiologic changes in our bodies that get us ready to either fight off an attacker, or run away if that is more prudent. Among other changes, such as an increase in heart rate, breathing, and blood pressure, the flow of blood is redirected away from some organs, such as the stomach and intestines, and towards others including the large muscles of the arms and the legs (necessary for fighting or running) and the skin (to enable better cooling while physical exertion levels are high). Less well known is that blood is also redirected away from the brain as part of the fight or flight response. That’s right, much of the brain is really unnecessary for fighting or running – the spinal cord and cerebellum can look after this on their own.

The consequence, then, of this reduced blood flow to the brain, is that we become temporarily stupid when angry. Our IQ drops! So making a decision about how to behave, what to do or what to say when we’re angry, is likely to lead to a poor outcome.

Is there anything that we can do to control angry behaviour if we have no control over our emotions, and anger weakens our capacity to think clearly?

The answer is: avoid the situations that get you angry. Learn to remove yourself from interactions that lead to anger, before you get angry. Thus, immediately when a patient starts to become abusive, we need to say “I’ll come back when you’re feeling better” and then leave. But we do need to come back after, say, five minutes, to see if the patient is “feeling better” and is ready to interact in a non-abusive way. If not, we repeat the same words and the same action (broken record technique).

Perhaps even more important is not going the extra mile for patients who will use it against us. Be scrupulously careful to not give more of ourselves for certain patients than we do for others, and also to not give less of ourselves.

If we fail to do this, we are likely to become angry at certain patients. Those patients will be able to detect our anger, even if they are not consciously aware of it, and will feel like victims of our angry behaviour. And they will be right, if we treat them less well then we would if we were not angry at them.

Attitudes are important. If we can accept our own anger as a normal response to being frightened or threatened, we need to accept that a patient’s anger is also a normal response to a fear-inducing situation. And, as for ourselves, controlling the angry behaviour induced by anger can be very difficult for patients. But as caregivers we are expected to put effort and energy into avoiding those angry behaviours, mainly by avoiding situations which we know will make us angry.

We cannot change other people’s behaviour, only our own. Thus, we need to develop a personal approach which we can apply consistently. It does not need to be the same as anyone else’s approach, but it is necessary to be consistent, so the patient can learn what he needs to do (or not do) to get good and timely care.

We expect cognitively intact patients to take responsibility for their behaviour, as we do for our own behaviour. This principle has certain consequences:

  • When a patient threatens us with physical violence (a criminal act) our response should be to call a code white.
  • Hiding medication (for example, crushing it and giving it in juice or jam, without informing the patient) is a powerful message to ourselves that we are willing to take responsibility for that patient’s behaviour, rather than the patient himself or herself (However, this may be appropriate with dementia patients).
  • When a cognitively intact patient refuses medication or treatment, we need to acknowledge that they have the legal right to do so. Our responsibility is to ensure that their refusal is an informed refusal, ie they are aware of the possible consequences to their health of not accepting treatment. Normally, the person who orders the treatment is responsible for informing the patient.
  • When a patient complains about us, we also need to acknowledge that they have a legal right to do so.
  • It may be appropriate to explain to the patient how they can go about making a complaint, and even to help them do so (for example, offering to provide a pen and writing paper to a bedbound patient).

All of the above take planning and practice. For an individual caregiver, working with a partner or mentor can be very helpful in achieving a more objective perspective on which interactions with a given patient are helpful, and which are problematic. Team meetings can also enable caregivers to share information about strategies that work or don’t work with certain patients.

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