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Difficult patients and families

June 2011

Type “difficult patient CME” into your browser and you’ll get literally thousands of responses. While most of the advice is good, the weakness of many of these courses is their unwillingness to admit that some problems just can’t be solved. As a result, you feel like a failure when sweet reason and clear communication don’t work. Rather than lay another guilt trip on you, let me describe some common situations and ways to minimize the damage both to patient care and to your own stress level.

Some patients and family members are determined to find something wrong with your work (or that of any doctor you transfer them to). They may think that a lawsuit is their ticket to riches or have an oppositional personality. Or they just want to look important by “standing up to the medico-industrial complex.”

So they sit in the patient’s room with a clipboard recording everything, and they bring in Internet articles to argue with every consultant. If keeping calm and explaining things doesn’t change this behavior, all you can do is get help from consultants and hospital administrators (including legal staff) and document everything. (On the plus side you probably won’t see them again after discharge; attorneys need more reasons to sue than “I didn’t like the doctor’s attitude.”)

Substance abusers can be endlessly creative, from playing for sympathy to filing complaints with hospital administrators. Try to put all your refusals in terms of safety: “I’m afraid to give you IV morphine because you might fall and be injured when you visit the cafeteria three times a day.” “The nurses tell me you’ve been getting meds so often that you sleep all day, and there’s a serious risk of aspiration pneumonia.” Avoid confrontations about falsehoods or expressing anger. “I feel really uncomfortable ordering that” is much harder for a patient to argue with than an accusation.

You’ve diagnosed what’s wrong and recommended a course of action, whether it’s surgery, rehab or a DNR order. But the patient or family refuses to listen, no matter how many CT scans you show them or how convincing the consultants are. Try to find out what motivates them, especially if they’re from a different culture. One Roma (Gypsy) family refused a lumbar puncture for their son because they hadn’t discussed it with the local elders. But they consented after a wise ER doctor pointed out that he’d cared for those same elders many times and that they trusted him to do what was best. Sometimes a chaplain or representative of a family’s faith can explain that what they need is not against their religion.

While we try to think the best of everyone, remember that not all families have the patient’s best interests in mind. They may refuse hospice because they’re collecting mom’s Social Security check, being blackmailed by a pastor or out-of-town relative, or just digging their heels in as a way to thwart an authority figure. They may be delusional or just unwilling to listen to someone with your kind of accent, ethnicity or gender. All you can do is keep the dialogue open, get information from nurses and social workers, and if the patient’s health is threatened, call adult or children’s protective services.