Dealing with challenging patients

Communication Skills

Demanding and unreasonable patients (or patients with a high IQ)

Challenges:

• Lack of experience• Emotional patients• Intimidating patients• Lack of background to

patients’ demands• Money• Resources• Conflicting messages from

other healthcare professionals

What to do:• Nothing• Document everything• Senior support, second opinion• Access ‘ICE’• Avoid ‘maybes’• Explain why for and not for• Avoid personalising conversation

What not to do:• Don’t give in to unreasonable

demands• Don’t argue• Don’t lie, or blag it• Don’t offer temporary measures• Don’t put yourself in danger

Patients with dementia or psychosis

Challenges:

• Lack of experience• Lack of insight• Aggression – paranoid• Multiple medical problems• Reliance of history from

relatives• Lots of social problems, inc.

alcohol and drugs• Medico-legal issues

What to do:• Safe environment• Chaperone• Low stimulus environment• Excellent communication

skills and patience• Non-judgemental

What not to do:• Don’t ignore physical health• Don’t rush the consultation

Patients with multiple or complex problems

Challenges:

• Time limitations• Spotting the red

flag• Satisfying the

patient• Lack of experience

What to do:• Give wiggle-room• Reassure• Clinical judgment• Prioritise• Bring back• Safety net• Documentation• Double appointments

What not to do:• Do not ignore / disregard• Do not get frustrated• Do not argue

Relatives of patients

Challenges:

• Different agendas• Multiple people

present• Family feuds• Emotional state• Unrealistic

expectations

What to do:• Preparation• Ask the patient what they want• Try to identify a point to contact• Suggest a formal appointment• Document conversations• Keep them informed• Nurse present• Keep patient main focus of care• Be honest and realistic

What not to do:• No transference / counter-transference• Don’t break patient confidentiality• Don’t make unrealistic promises• Don’t take sides

Patients with personality disorders

Challenges:

• Communication issues• Consent / capacity• Unpredictable• Staff safety

What to do:• Stay very calm• Involve Psychiatry

What not to do:• Don’t confront patient

Prejudiced patients

Challenges:

• Might not agree with treatment

• May compromise their care

• May think they know better

What to do:• Educate them• Time to think• Offer alternative care• Remain unbiased

What not to do:• React to prejudices• Take it personally

Manipulative patients

Challenges:

• They say the right things to get what they want

• They have knowledge of the system

What to do:• Make team members

aware• Involve other

healthcare professionals• Negotiate

What not to do:• Don’t confront them• Don’t pander

Suicidal patients

Challenges:

• Defensive medicine• Risk• Sustaining empathy• Prejudice• Establishing trust

What to do:• D/w another medical professional• Risk assessment scoring• Advice from Crisis team• Check previous notes• Ask about protective factors• Let them talk• Good documentation• Keep an open mind

What not to do:• Don’t give tips• Don’t dismiss concerns• Don’t be judgmental• Care with prescribing

DNAR (Do Not Attempt Resuscitation) patients

Challenges:

• Patient / family refusal• Conflicting opinions in the team• Patient not fully aware of illness• Respect• Experience & information• Emotional / upsetting• Fear of being misunderstood /

passive• Balance between Guidelines

and Policies and Ethics

What to do:• Discuss with seniors, MDU/MPS,

seniors, family, patient• Have a go• Ensure private setting /

chaperone• Document properly, explain

clearly, facilitate audit• Take your time, express empathy

What not to do:• Don’t make decision alone• Don’t act in public• Don’t be lax with documentation

Aggressive (especially drunk) patients

Challenges:

• Low inhibitions• Low levels of

consciousness• Difficult to treat /

refusals

What to do:• Protocol

What not to do:• Don’t rise to the bait• Don’t miss potential

injuries• Don’t judge them

Child patients / patients with low IQ

What to do:

• Non-verbal communication

• Charts, pictures, toys• Examples, e.g. on teddy• Use mother / carer

What not to do:

• Don’t patronise• Don’t speak really

slowly• Don’t use complicated

language / jargon

Patients who speak a different language

What to do:

• Use qualified interpreters• Ask patient to summarise• Non-verbal

communication

What not to do:

• Don’t use children to translate

• Don’t speak only to interpreter

• Don’t use too many closed questions

Patients who have difficulties in expression (e.g. dysphasia, deafness)

What to do:

• Check understanding• Non-verbal

communication, e.g. blinking, writing

• Collateral history

What not to do:

• Don’t rush• Don’t presume the

patient is dumb

Patients with communication barriers

Challenges:

• Misunderstandings• Frustration• Harder to build rapport• Time – takes longer• Interpreters (dilution of

communication, confidentiality)

• Cultural issues

FY2 communication:Useful tools from the field of

Psychology

Dr Julie HighfieldClinical Psychologist

Cardiac Rehab and Renal Services- UHCW

Areas covered

The following are some ideas from the field of clinical psychology which may help you when considering why some interactions with clients can be difficult. It is not intended as an exhaustive list.

The kinds of things covered are:Some thoughts on why patients may struggle to adhere to your advice. This

includes thinking about how patient represent illness (from Leventhal), and from psychodynamic ideas, and motivation for change (with ideas from motivational interviewing).

Some thoughts on the way in which a patient may act and how this shapes our behaviour and then their behaviour in turn- drawing from Transactional analysis, reciprocal roles (CAT), and transference.

To help you think about adherence• Self-efficacy: Does the patient believe in her ability to

carry out the required action? How can you encourage this?

• Locus of control: does the patient believe that his health is his responsibility or down to others? This affects what he would be willing to do for himself, and what he expects of you.

• The representation of illness- Leventhal, next slide• Doctor-patient communication (Transactional analysis,

cognitive analytical perspective- see later)• Is the experience of psychological distress impacting

upon a patient’s ability to self manage? Can you ask for advice from psychology related to you area?

Self-regulatory model of illness behaviour (Leventhal)

Stage 1: The patient interpretstheir illness

Thoughts about health threat:What is it?Cause?ConsequencesHow long for?Cure/ control

Emotional responseto health threat:- Anger- Anxiety- Depression

Stage 2:copingStyle:ApproachAvoidance

Stage 3: AppraisalWas my coping strategy effective?

Leventhal (cont)

How the person interprets their illness• Identity “what do I have?”• Cause “why did this happen?”• Timeline “How long will I feel unwell?”• Treatment “What is the treatment?”• Curability “Will I be 100% well again?”

• These beliefs shape illness behaviours

Patients approach to chronic illness:Ideas from a psychodynamic perspective

The symbolic nature of treatment:

it makes me feel different (PAST negative experiences of feeling different and being treated badly for this)

it controls my life (PAST negative experiences of being controlled byothers)

it stops me from being able to do what I would like to – (PAST experiences of restriction)

it means that I will be viewed as “less” (PAST experiences of rejection andabandonment)

it is another punishment (PAST experiences of abuse)

Non compliance can also be a way of self-destructing, arising from hopelessness

Motivational InterviewingMiller and RollnickMotivational interviewing is a directive, client-centered counseling style for

eliciting behaviour change by helping clients to explore and resolve ambivalence

The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence

NOT persuasionNOT advice giving

BUT:1) Open-ended questions2) Affirmations3) Reflective listening 4) Summaries.

Principles of MI• Motivation to change is elicited from the patient, and not

imposed from without. • It is the patient's task, not the doctors, to articulate and resolve

his or her ambivalence. • Direct persuasion is not an effective method for resolving

ambivalence. • The style is generally a quiet and eliciting one. • The doctor is directive in helping the patient to examine and

resolve ambivalence. • Readiness to change is not a patient trait, but a fluctuating

product of interpersonal interaction. • Emphasis on freedom of choice rather than doctor as expert

Stages of ChangeProchaska and DiClemente (originally 1982) produced amodel of behaviour change that is used within Motivational Interviewing.

Not linear, but dynamic:

1. Pre-contemplation: not intending to make changes2. Contemplation: considering a change3. Preparation: making small changes4. Action: engaging in a new behaviour5. Maintenance: sustaining the change over time

Thus different approaches by HCPs to patients neededaccording to stage.

The stages of change model is useful when considering poor health behaviours (e.g. smoking, drinking alcohol). A person is unlikely to take your advice and “give up” until they are ready to do so

Transtheoretical Model of Change (Prochaska & DiClemente, 1983)

Stages of change (2)• At different stages, the individual weighs up the costs and benefits in

different ways.• Eg: smoking

1. Precontemplation: “I am happy to be a smoker” “Stopping smoking will make me anxious”

2. Contemplation: “I’ve been unwell, perhaps I should give up smoking”3. Preparation: “I will cut down on smoking”4. Action: “I have stopped smoking”5. Maintenance: “I have stopped smoking for several months, and I feel

healthier”

MI style questions that may be of use

• What concerns you about …. ?• What is good about the way things are at the

moment? Not so good?• What would be the worst case scenario if you

didn’t make any changes?• If you were going to set a goal, what would it

be?• Acknowledge challenges, emphasise personal

choice, build confidence based on past success

Cognitive problems• Memory

– Present information first– Provide specific, not general recommendations– Restrict the information to what the patient can process at the time– Organize the information e.g. by importance, time (what to do first,

second), or type (benefits of treatment, side effects)– Use of oral & written information– Repeat important information: if necessary in a follow-up meeting or

by providing an audio tape

Considering patient interactions

• Their effect upon us and how we affect them!

1. Transactional analysis2. Reciprocal Roles (CAT)3. Transference

Transactional Analysis

• Arises from Eric Berne• Interactions between people (transactions)• Within transactions, individuals adopt one of three

ego states:1. PARENT (either critical or nurturing)2. ADULT3. CHILD (either free child or adapted)

On a ward, health care profs can find themselves becoming parental. This can mean our patients end up acting in a child ego-state.

Adaptive interactions are adult-to-adult

TA: ward example

parent parent

adultadult

child child

“Could you explain the procedure again? (I’m frightened)”

“There really is nothing to worry about!”

Patient: Professional:

The patient asks an adult question, but is dismissed. The patient may then act “childishly” as a result

TA: ward example (part 2)

parent parent

adultadult

child child

“Could you explain the procedure again? (I’m frightened)”

“Certainly…”

Patient: Professional:

The patient asks an adult question, and is treated like an adult. The interaction continues in an adult-adult manor”

Drama Triangle- part of TransactionalAnalysis

If we go above and beyond the call of duty with patients, we may fall into rescuer role.

Drama Triangle

It is useful to be mindful of when you are rescuing.

• Risks of rescuing:– End up becoming the victim through constant

focus upon others, or the rescued may point the finger of blame

– Risk ignoring the choices and self-efficacy of others by making decisions for them

– When rescuers are burnt out they become persecutors- “getting my way”

Transference and Counter-transference

• This will have been covered in previous teaching, but a reminder…..• In every patient interaction, health care professionals may be perceived as

symbolic care givers• They may respond to us as if we are former/ current people in their lives

(e.g. their mother, father, brother etc).• We may in turn respond to this.• It is helpful to be aware of how this may occur, and to not be drawn in to

reacting in a non-professional manner.

• The following slide on reciprocal roles will help you consider this.• For example, a person may expect that we will do everything for them,

and we may be drawn in by their helplessness. Or a patient may expect that we will let them down, and will be dismissive of our treatment, which may lead us to dismiss them in return.

Reciprocal Roles (CAT)patient: Team:

non compliantsabotage treatment

demanding“rubbish” treatment

FrustratedIrritated

RejectingCynical

Critical of each other

High self efficacyInternal locus of control

EmpoweredAble to make choices

InformingNon persecutory

Clear boundaries and contract with patients

Helpful but not controllingContaining

HelplessNeedy

Stringently compliant

HeroicOver-involved

Break boundariesHelp too much

Foster dependence

The way in which we respond affects the patient, and the patient’s response affects us. (from Ryle)