The Difficult Patient

Introduction

Few calls inspire more dread in the on-call psychiatrist than those regarding a “difficult patient.” It can be tempting to quickly determine via phone that a clash between a patient and treatment team is not driven by mania, delirium, or psychosis and then try to “cancel” the consult. However, it is with these patients, perhaps more than any other, that we have the opportunity to repair a broken patient-team relationship to allow optimal medical care to proceed. Sometimes the patient-team relationship has fractured to such a degree that we are consulted to determine the capacity of a patient who is demanding to leave against medical advice. Those on the other end of the phone may be angry, frustrated, demoralized, exhausted, or afraid. As the psychiatrist consultant, our first priority in these consults is to support the team and ensure the patient’s and staff’s immediate safety. Our second aim is to identify sources of conflict between the patient and the team and to formulate a plan of action with treatment recommendations for acute stabilization. During this step, we supportively diffuse tensions and validate each side by playing to their strengths (see examples later). Our third goal is to educate and align the patient and team, providing a framework for future interactions. Depending on the acuity of the consult, not all of these steps may be completed overnight, but your goal should be to set the groundwork for ongoing effective communication between the two parties.

The Consult

By the time a consult for a difficult patient is placed, the staff and patient have likely hit an impasse in communication and expectations. Those calling may have difficulty expressing the reasons for the consult, but you can begin to collect clinical data during this initial conversation. If the patient is aggressive or suicidal, for example, you may hear a frightened call for help. If the request sounds exhausted or depleted, the patient may be emotionally demanding, clingy, or dependent. If the request sounds angry and frustrated, it may mean the patient has become hostile and team members are feeling manipulated. Requests may be vague or confusing if the patient’s perception of reality is altered (e.g., due to denial, psychosis, or cognitive limitations). It may be apparent to you that staff is split in disagreement or are having difficulty coping with their own reactions to the patient (e.g., anger towards the patient without recognizing why, seeing the patient as wholly bad or wholly good, distorting or denying the current situation, becoming passive aggressive, projecting emotions onto the patient). These observations will all help to shape your initial approach and interaction.

Make sure to talk with the team directly regarding their concerns. Listen for the way they characterize the problem. Then, assess acuity as quickly as possible by asking questions such as:

• What is the patient’s behavior at this very moment and when did it start?

• Is this an abrupt behavioral change?

• Is he/she alert and oriented? Assaulting staff? Screaming and threatening? Pulling out intravenous (IV) lines? Or is he/she lying in bed asleep?

• Are staff feeling scared?

• If the patient is agitated, has anyone attempted verbal redirection? Is it working?

• Has the patient been offered stat doses of as needed medications? Which ones?

• If the patient is not responding to redirection and sounds acutely dangerous, have hospital police been called?

• Is one-to-one arm’s length observation necessary?

After asking these questions, you should be able to determine whether the patient’s presentation is acute or nonacute. If you are unclear about this, make your way to the patient and staff to further assess.

If the presentation sounds acute, make sure hospital police have been called and additional support is available before ending the call and going to see the patient. If your hospital has a behavioral emergency system in place (e.g., a behavioral code), tell staff to activate it while you make your way there. If you foresee intramuscular (IM) medications or behavioral restraints becoming necessary due to acute dangerousness, inform staff to draw up requested medications and obtain restraints. Ask about the patient’s most recent vital signs, orientation, medical problems, substance use history, and current medical stability. Confirm any medication allergies and review current medications.

If the patient’s presentation sounds subacute, assess if the team is worried that things will soon escalate. Often, staff has a sense for this. If immediate escalation is of less concern, attempt to ascertain a concrete consult question—does the team want a recommendation for as needed medications? Are they concerned about the patient’s capacity regarding specific decision-making? Would they like assistance creating a behavioral plan for a patient with poor boundaries? With a little help, the reason for consultation should become clearer. However, at times, things may not be obvious until you see the staff and patient in person.