“He is NOT staying here!” the elderly woman shouted, her voice rising rapidly. You glanced around quickly, conscious that others in the Emergency Department would hear the disruption.
You had explained that her husband, 73-year-old Barry, would need to be admitted to the ward. He had a fever and dehydration with a high white cell count and CRP as well as high urea and creatinine levels which required further investigation. Barry’s wife Eileen was adamant she would take her husband home, and he was not spending a single night on the ward. The more you discussed it, the more hysterical she became.
This was not the way you had imagined starting your first week as an RMO in the emergency department!
Every job involving interpersonal contact will involve difficult interactions. This is especially so in medicine, where both stakes and emotions run high.
Fortunately, there are some guiding principles to help when you find yourself in confronting situations. Understanding your rights and responsibilities will also assist you in dealing with difficult patients or family members.
Recognise the issue
The first skill is being able to recognise a difficult situation, where for instance your expectations and those of the patient or their families diverge. As in this scenario, this may be that the patient wishes to leave against advice, and they place themselves at risk by doing so.
You may also encounter situations in which the wishes of the patient and of their family differ. In the scenario above, it is clear what Eileen wants, but what does Barry want?
Recognising a potential issue early gives you an opportunity to defuse the situation before it escalates, or seek support from a colleague in managing the conflict.
Understand the issue
Anger and aggression are rarely found in isolation. More often they are symptoms of an underlying concern. Patients and families are already in an unusual, frightening and stressful situation. In addition, every individual has their own set of personal experiences and fears that may influence their preferences and their reactions. While they may be aggressive towards you, it may not be about anything you have said or done. It’s important not to take it personally, and to try to understand the deeper concern so you can address the real issue.
If you explore the situation with Eileen some more, you may find out she and Barry have rarely been apart in nearly 50 years of marriage. She is terrified of being alone even for a few nights. You might also learn that three years earlier their daughter died in this hospital following a horrific accident. Eileen is convinced that Barry’s admission will also lead to his death.
Knowing where Eileen’s fears lie allows you to better understand her view, and to directly address her concerns. For example, you may want to explore whether a friend or family member could stay with her while Barry is in hospital. Explaining exactly what tests are necessary and what to expect on the ward may also help. You may not be able to completely remove the fear, but you can provide support by understanding and addressing the actual issues. This can also help in building rapport, which may lead to a more productive approach.
There are of course times when exploring the real issues will not resolve the conflict – in these cases, it is important to be sure of where your legal and ethical obligations lie.
Capacity and consent – your duty of care
Your legal duty of care is to your patient. Provided the patient has capacity to understand the nature of their decision, it is up to them whether to undergo treatment or not. If a constructive relationship cannot be forged with the patient’s family, continue to be courteous and respectful, but direct your conversation to the patient themselves. Remind the patient the decision is theirs.
A patient’s decision is only valid if it is given without coercion, and you need to be able to satisfy yourself the patient is fully informed and making their own decisions. In some situations, you may need to ask to speak to the patient alone to ascertain what their views are. Remember you have the right to ask the family to leave while you have this conversation, and the right to request security’s attendance if the family refuse to comply. This of course would be a last resort.
Informed consent is a familiar concept, however it is potentially even more significant to recognise the flip side: informed refusal. A patient with capacity who has been fully informed of the risks has the right to refuse treatment. The difficulty for doctors, particularly when a patient wishes to discharge against advice, is being sure the patient has been fully informed and understands the risks they take by refusing treatment.
For informed consent or refusal to be valid, the patient needs to have all the material facts that may affect their decision. Clearly explain the condition, and what further tests or treatment need to be performed. Be sure to explain why these measures are necessary, and what might happen if the patient refuses.
Do not be afraid of using blunt language – it delivers a powerful message about the gravity of the decision the patient faces. Although it may feel unnaturally direct, it helps the patient understand their decision.
For example, tell Barry there is a risk that he is septic and could die if it is not investigated and appropriate treatment commenced. Ensure he knows and understands the worst case scenario.
Similarly, you can use language to remind the patient of your role in their decision. Using words like “I have a duty of care to act in your best interests,” or “I have an obligation to provide you with all the details so you can make an informed decision” can remind the patient you are a professional, there to help them in making an important decision.
Using emotive phrases such as “I’m worried that if Barry leaves now…” or “I’m concerned that if he doesn’t have these tests …” also helps to align yourself with the family in your concern about the wellbeing of the patient. It helps remind the patient and their family you’re on their side, and interested in what is best for the patient.
As always, ensure you keep thorough and accurate records. This is especially important in a difficult encounter. Particularly if a patient wishes to discharge against advice ensure you specifically document the warnings you provided. As far as possible, use the exact language you used with the patient. Even if you are asked to get the patient to sign a discharge against medical advice form, it is essential you also document the nature of your conversation in the medical records. In addition, ensure the person who witnesses the interaction with the patient and/or their family also makes a record in the medical notes. Two accounts are better than one.
Remember the patient has a right to request their records at any time, so be careful to use neutral and respectful language. However, it is also important you accurately document any conflict, your considerations, the steps you took and any decisions made or follow-up action.
Do not take these decisions on your own
Faced with any difficult interaction, do not hesitate to call for backup. Having another member of staff as witness and support will only help you in managing the situation, both at the time and in case of future repercussions. Offering a second opinion from an independent colleague may be helpful in managing the patient’s concerns. However, support does not have to come from a senior clinician or another doctor. Nurses have extensive experience managing difficult situations or personalities and can provide invaluable support. Social workers or the hospital patient representative may also be available to assist.
If the patient insists on leaving, ensure another member of staff witnesses you explaining your concerns to the patient and your reasons for wanting them to stay for treatment. You should notify your immediate senior as well as the admitting medical officer of the patient’s views.
At this point Barry and Eileen’s son Michael arrived. A burly man with an intimidating physical presence, Michael became quite aggressive when he saw his mother was so distraught. All he saw was that you were upsetting his family.
This can be a scary situation. However, your personal safety is a priority and you should only continue examining or treating the patient if it is safe to do so. You may need to ask family members to leave, and if they refuse you have every right to ask security to attend while you continue to see and assess the patient. Ensure you are familiar with the hospital’s safety protocols and know how to seek assistance when required. Do not continue if you feel unsafe, never go into a closed room with an aggressive patient or family member, and always ensure you have a clear path to an exit.
Look after yourself
You cannot look after anyone else if you do not look after yourself first. Difficult encounters will be made even more difficult and upsetting if you are already tired, stressed, upset or unwell. Looking after your own health is essential in being able to help others, and manage the obstacles of a challenging career. However looking after yourself does not mean trying to deal with issues on your own. Debriefing about the incident in general terms with a trusted colleague or friend can be very helpful.
Difficult interactions, whether with patients or their loved ones, can be confronting and upsetting. Unfortunately they are a reality in the medical profession, and while you cannot avoid them altogether, you can equip yourself with sufficient knowledge and confidence in your own rights and obligations to navigate them with some ease. It will take time, practice and many confidence-testing situations to get there, but remember every single medical professional goes through the same experience. Try not to be embarrassed, upset or self-conscious – everyone has been there, and it is simply another aspect of learning and improving your practice.