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].

与困难患者沟通受损的危险

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

  1. 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.
  2. Start with a good first impression: Smile, use an open posture, introduce yourself, extend your hand for a handshake, look patients in the eye for 3-5 seconds (seeEpisode 49 on Effective Patient Communication)
  3. 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”.
  4. 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

  1. 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.
  2. Acting “dumb”:当受到威胁或攻击时,不要反击;要求澄清问题以改变攻击澄清。你可以说“赦免”或“帮助我了解你所说的”或“我不明白你想要说的话”,即使你准确地了解病人的说法。使用非对抗性肢体语言。
  3. 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

如果没有通过困难的病人进行的进展,请考虑说“这不顺利。我们可以再次开始吗?“

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).

焦虑的病人

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.

For more on how improved physician-doctor relationship can improve patient care readDuncan Cross的帖子在Kevinmd博客上

In the primal sympathy
Which having been must ever be;
In the soothing thoughts that spring
Out of human suffering.
- 从威廉·奥斯勒先生的医学书历史。

Breaking Bad News

Bring colleagues who can assist the family (i.e. social work, nursing).

Non-verbal communication strategies: Sit down and establish good eye contact. Use pauses in order to let the family or patient react.

SPIKES Mnemonic for Breaking Bad News

  • Setting: Find a quiet, private place to disclose the bad news
  • Perception: Understand the patient’s perception of what is happening and what the patient already knows
  • Invitation: Get an invitation from the patient to provide the information and determine how much the patient or family wants to know. ”

    Some people prefer a general picture of what’s happened and others prefer knowing all the details. Which would you prefer”

  • Knowledge:对死亡或疾病的缩短,相对快速简洁的描述,其次是警告(“我即将告诉你的事情很重要)。然后以清晰简洁的方式,告诉他们结果。使用死亡或死亡而不是'过去'。一定要避免医学术语。
  • Emotional Supports:提供的移情和支持,如“I can’t imagine how terrible this must be for you” or “this is very difficult news for you”
  • Summarize: summarize what has happened and what will happen next; state a plan of action

A moredetailed description of the SPIKES mnemonic.

Disclosing a patient death:

直接和温和,始终快速汇总导致死亡的步骤。准备患者/家庭成员的坏消息“我担心我有一些坏消息”。不要使用模糊的术语。不要说“我知道你的感受如何”,因为这可能引起一个像“你不知道我的感受”等回应。考虑说“我很抱歉你的损失”。

Discharge Instructions

卸货指令是急诊部门记录的一个非常重要的部分。确保患者对这些说明进行了解5.

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.

Update 2015:Excellent review处理想要留下医疗建议的困难患者。

Update 2015:Practical framework用于管理挑战性患者遭遇。

Quote of the Month – Mark Twain

“Always do what is right. It will gratify half of mankind and astound the other.”

New York Times article “Can Doctor’s be Taught to Talk to Patients

For more on patient centered care on EM Cases:
Episode 49 Effective Patient Communication, Patient Centered Care and Patient Satisfaction

Dr. Helman, Dr. Himmel, RN Shook and Dr. Champagne have no conflicts of interest to declare

关键参考文献

  1. Brinkman, R. & Kirschner, R. Dealing with people you can’t stand. New York: McGraw-Hill, In. 1994.
  1. Decker, B. You’ve got to be believed to be heard. New York: St. Martin’s Press. 1991.
  1. Baile,W.f.等人。尖峰 - 提供坏消息的六步协议:患有癌症的患者。2000年。肿瘤科医生,5(4):302-11。全文可用:http://theoncologist.alphamedpress.org/content/5/4/302.full
  1. 巴克曼,R.打破坏消息:S-P-I-K-E-S战略。2005.心理社会肿瘤学,2(2):138-42。全文可用于:http://www.oncologypractice.com/co/journal/articles/0202138.pdf
  1. 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
  1. Waisman, Y et al. Do parents understand emergency department discharge instructions? A survey analysis. 2003. Isreal Medical Association Journal, 5(8): 567-70. Access to full text at:http://www.ima.org.il/IMAJ/ViewArticle.aspx?year=2003&month=08&page=567
  1. Engel, K.G. et al. Patient comprehension of emergency department care and instructions: Are patients aware of when they do not understand? 2009. Annals of Emergency Medicine, 53(4): 454-61. Access to abstract at:http://www.ncbi.nlm.nih.gov/pubmed/?term=Patient+Comprehension+of+Emergency+Department+Care+and+Instructions%3A+Are+Patients+Aware+of+When+They+Do+Not+Understand

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?

您如何应对令人生畏的患者,因为您的护理计划不会与其固定的妄想或其先前的异国情调(MIS)诊断同步?

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.

For Part 1-Episode 49 on Effective Patient Communication