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 Shooktake 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
Cite this podcast as:Himmel, W, Champagne, J, Shook, R. Effective Patient Communication – Managing Difficult Patients. Emergency Medicine Cases. //www.mp3valve.com/episode-51-effective-patient-communication-managing-difficult-patients/. Accessed [date].
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
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.
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”.
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
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.
Silence: Give the person time to calm down; the person usually burns out within 60-75 seconds
If all else fails…..
Time Out:从沮丧如果你遇到休息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 your意图: “I’m here to do what is in your best interest”
Next determine the patient or family member’sinterests要么agenda. Say “I can see you are concerned; what is your major concern right now?”
Then, ask for theircooperation. 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
Ending the interaction: have a明确的计划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).
患者对类似sympto重复访问ms, 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.
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.
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
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?
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.
Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.