1. Nicholas J. Kockler, PhD, MS & Lisa Dashiel BSN, RN
Nursing Grand Rounds:
December 2012
Caring for the ‘Difficult Patient’: Ethical Issues When Patients Do Not Adhere to Medical Advice
Nicholas J. Kockler, PhD, MS
&
Lisa Dashiel BSN, RN

2. The ‘ethical’ truth: We have not been bribed (no one has tried).
We are not being paid to say or not say anything we would not otherwise say or not say.
Everything we say or do not say is on the up-and-up.
All our motives are honorable.
Erin / Liz – disclaimers / disclosures 

3. Objectives
To recognize difficult patient encounters and their ethical issues
To identify a range of strategies that might help improve care in so-called difficult patient encounters

4. Case 1
After his recovery from surgery and placement of a halo and PICC, a patient with cervical osteomyletis wishes to go outside the hospital for a smoke. He has a history of heroin use, and his girlfriend is suspected of bringing him drugs. His father is en route, but they have a strained relationship. The patient escalates his threats to leave against medical advice if not allowed to smoke. Most clinicians agree that this patient has capacity even though they disagree with the risks he wants to take. The patient has refused nicotine patches.

5. Question for iClickers: Case 1 What is the most compelling ethical option?
Discharge the patient against medical advice because he cannot be trusted to smoke off-campus alone.
Have nursing chaperone the patient out to smoke.
Have his girlfriend chaperone him out to smoke.
Have his father chaperone him out to smoke.
Place a “medical hold” for this patient and physically restrain him in his bed.

6. Case 2
A 28 year-old patient presents with infective endocarditis for the 2nd time. He has a history of intravenous drug use, and he has already received one valve replacement for a previous bout with endocarditis. The patient does not appear to have insight into the relationship between his drug use and his infection. He has never participated in a detox / recovery program. The surgeon wonders if he should perform another valve replacement even though it is medically indicated.

7. Question for iClickers: Case 2 What is the most compelling ethical option?
Perform the valve replacement and be very aggressive with offering chemical dependency treatment.
Do not perform the valve replacement, the patient has demonstrated he is non-compliant with medical advice.
Perform the valve replacement this time and as many times as he needs throughout his life: his lifestyle choices should not lead to our discrimination against him.
Do not perform the valve replacement until the patient shows a willingness and commitment toward recovery.
Perform the valve replacement, be aggressive with chemical dependency treatment (offering of it), and teach the patient how to obtain and use clean needles for his drug use.

8. Case 3
A 32 year-old woman is admitted through the ED with a rectal foreign body. She has an active history of daily heroin use. The foreign body was surgically removed. On the morning of discharge she becomes irritable, agitated, demanding immediate discharge and throwing things in her room. Security is called for support. Taxi transportation is called and patient is taken to the lobby to wait for its arrival. On the way out of her hospital room, she casually mentions that she was raped, whereas prior to that she had said the foreign body was from consensual sex. It is 48 hours since she was admitted to the hospital. Security is waiting with her in the lobby. After conferring with the physician and ED charge nurse, the patient’s nurse and RN Care Manager go to the lobby to talk with the patient. She appears sedated, having a difficult time keeping her eyes open. Appearance of sedation acknowledged by staff and patient was asked if she had taken any substance other than the two Percocet her nurse had given her three hours earlier. She said, “No”. Staff told her they were concerned about her statement of being raped.

9. Question for iClickers: Case 3 What is the most compelling ethical option?
Take patient back up to the nursing unit and cancel the hospital discharge.
Take the patient to the ED for a sexual assault work up and to monitor sedation.
Call the police to report a rape.
Insist on a Psychiatric Liaison assessment before she can leave the hospital.
Allow her to leave the hospital once her transportation has arrived as she has already been discharged.

10. Case 4
A 36 year-old patient well known to the ED came in with an ingested foreign body (a pen). After initial work-up, it was determined that another emergent endoscopy (the 6th in 5 months) would be needed to remove the object safely. Clinicians report that the patient is difficult to work with as he is very demanding of staff, persistent about requesting pain medicines, and refuses to see a primary care provider as an outpatient. The endoscopy is performed and the patient immediately leaves against medical advice. The patient demonstrates behaviors consistent with a personality disorder and bipolar disorder, but a formal psychiatric evaluation is nearly impossible because the patient consistently leaves post-surgery before the psychiatric-liaison service can see him. It is only a matter of time before he returns to the ED. The patient has no insurance.

11. Question for iClickers: Case 4 What is the most compelling ethical option?
Perform the endoscopy and proactively discharge him early.
Do not perform the endoscopy as he is stable, do not admit him; evaluate in the ED only.
Require the patient to see the psychiatric-liaison consultant as a condition of performing the endoscopy.
Perform the endoscopy, enact care plan consistent with best practices / standards of care (even though he is likely to leave early).
Place a “medical hold” for this patient and physically restrain him in his bed until we are confident he is ready to be discharged.

12. Prevent Default Decisions Minimize Moral Distress
Provide
Practical Wisdom
Prevent Default Decisions
Ensure
Integrity
Reduce Moral Hazards
Promote
Freedom
Minimize Moral Distress
techné
praxis
ethos

13. Ethical Decision-making Model (Clinical)
Clinical Integrity
Beneficence
Autonomy
Justice / Nonmaleficence
Ethical Decision-making Model (Clinical)

14. Foundational Questions…
Is this an honest / right practice of medicine?
Do my actions demonstrate professionalism?
Clinical Integrity
Is this intervention / practice dependable for delivering clinical benefit?
Beneficence
Are we fair to the patient in consideration of his/her worldview and life plan?
Autonomy
Can we explain protections for this patient or for others? Can we account for our actions in light of broader traditions?
Justice / Nonmaleficence

15. Moral Hazards in Difficult Patient Encounters
Risk of decision-making following an ad hominem judgment (logical fallacy): Exclusively blaming the difficulty on the patient, myopia of what else might be going on
Self-fulfilling prophecy
Groupthink
Diffusion of responsibility
Therapeutic nihilism: The idea or bias that such patients can’t be helped
Patient abandonment: Prematurely or inappropriately “firing” a patient
Risk of harm to self or other by patient

16. Demonstrate model (Large Group)

17. Internal Indicators of Physician Strategies Dependent Clingers
Name
Description
Internal Indicators of Physician
Strategies
Dependent Clingers
Escalation from mild/appropriate requests for reassurance to endless, repeated requests for all forms of attention; naïve about effect on physician; self-perception of bottomless need and of the physician as inexhaustible
Aversion to the patient
(may begin as a feeling like “puppy love” to the patient due to expressions of gratitude made by patient)
Inform patient early, tactfully, and firmly of limits and realistic expectations
Entitled Demanders
Similar to clingers in neediness, but use intimidation, devaluation, and guilt-induction to control doctor; may threaten punishment; patient likely fears abandonment; exude innate deservedness
Fearful of impact on reputation, enraged that patient is not cooperative/grateful, [secretly] ashamed as if patient’s demands/comments are realistic
Never challenge patient’s sense of entitlement, but rechannel it toward indicated therapy; repetition of theme of acceptance and redirecting/reframing of patient’s demands
Manipulative Help-Rejecters
Have profound neediness, but they are not seductive and grateful (cf. clingers) and are not overtly hostile (cf. demanders) – they feel no regimen will help: they are pessimistic, which may appear to increase in direct proportion to doctor’s efforts and enthusiasm; desire is relationship with caregiver, not necessarily relief of symptoms
Anxiety about comprehensiveness in care; irritation with the patient; and then depression and self-doubt
May be helpful to ‘share’ patient’s pessimism; use of regular follow-up visits determined by the doctor may help with maintenance (and patient’s fear partly allayed); if psychiatric referral is indicated, scheduling another appointment after the consultation may communicate the persistence of the doctor-patient relationship
Self-Destructive Deniers
Displays of unconscious self-murderous behaviors; at baseline very dependent and given up hope of ever having needs met; may appear to find pleasure in defeating physicians attempts to preserve his/her life; “chronic suicidal behavior”
Wish that patient would die and “get it over with”; malice toward the patient may transform into guilt or self-reproach or into dread, self-blame, hopeless attitude; may evoke all of the other negative emotions as described above
Options are quite limited; psychiatric consultation (to assess whether treatable depression is present); perseverance to provide compassionate care; consider reframing care plan toward palliative and/or harm reduction goals; avoid abandonment

18. Two Questions: What makes the encounter with this person difficult?
What makes this person a patient?

19. Difficult Patient Encounters: What’s in the Differential Diagnosis?
Rule-out psychiatric / neurological illness
Rule-out psychosocial stressors
Rule-out cultural and linguistic barriers
Rule-out systemic barriers
Rule-out logistical or practical barriers
To answer question 1, consider the differential diagnosis…

20. Therapeutic Relationship
Difficult Patient Encounters: What’s the basis of the therapeutic relationship?
Do you agree on goals?
If no, what’s your BATNA*?
Do you agree on interventions?
Do you have a bond with this patient?
If no, how can you bridge the gap?
Therapeutic Relationship
Goals
Tasks
Bond
To answer question 2, consider three components to the therapeutic relationship… If you don’t have any one of these, there may not be a therapeutic relationship.
While Goals of Care are of primary importance, a Bond is a necessary and sufficient condition of having a “therapeutic” relationship. Think of “bonds” to which we are bound by law.
*BATNA = Best Alternative To No [or Negotiated] Agreement”

21. Benefit versus No Harm Beneficence Nonmaleficence Obligations…
to support and provide medical goods (benefits)
to protect others from harm
Obligations not…
to inflict harm, or
to expose to risks of harm
Whether there was an absence of due care (negligence) by respecting patient choices in the context of continuing the therapeutic relationship
Acute
Cure / Fix
Rescue
Chronic
Manage illness
Palliative
Manage pain, symptoms, and QoL
Professional model of due care (B&C, p. 154):
-The professional must have a duty to the affected party;
-The professional must breach that duty;
-The affected party must experience a harm;
-The harm must be caused by the breach of duty.

22. Harm Reduction Care Planning
Demonstrate hospitality: Walk the line between tolerance and intolerance
Guard against complicity by offering a range of services to address undesirable behavior (e.g., substance use) and yet acknowledging its occurrence
Set parameters for cooperation with illicit or undesirable behavior
Craft care plans to
Reduce the negative consequences of bad behavior when they happen
Manage the risks of bad behavior through diligent monitoring and other preventative strategies when feasible
Establish [intermediate?] goal as harm reduction, not benefit per se (in light of continuation of bad behavior)
Enhance patients’ abilities to comply with medical advice (incentives, deterrents, etc.)
Acknowledgement is not endorsement if therapeutic relationship is based on mutual understanding that practitioners wish patients to end choices that prohibit or inhibit achievement of medical good/clinical benefit for the patients… Acknowledgement as tolerance can be an implicit endorsement whereas acknowledgement in the context of caring hospitality can be “tolerance” with a desire or wish to change behavior or make it safer if it is to continue.
Hospitality – Tolerance – Complicity – Cooperation (a spectrum of the therapeutic relationship in harm reduction?)

23. Question for iClickers: Case 4 (Revisited) What is the most compelling ethical option?
Perform the endoscopy and proactively discharge him early.
Do not perform the endoscopy as he is stable, do not admit him; evaluate in the ED only.
Require the patient to see the psychiatric-liaison consultant as a condition of performing the endoscopy.
Perform the endoscopy, enact care plan consistent with best practices / standards of care (even though he is likely to leave early).
Place a “medical hold” for this patient and physically restrain him in his bed until we are confident he is ready to be discharged.

24. Difficult Patient Encounters: When to ask for an ethics consult?
When there is concern or uncertainty about any of the following issues:
Duty to protect patients from self-harm
Obligation to benefit/offer services/continue care
Severing therapeutic relationship vs. setting
Justice obligations to protect self / staff from threatening patients

25. Difficult Patient Encounters: What can an ethics consultant do?
Reframe the problem
Model curiosity about the patient as person
Suggest refocusing on goals of the medical encounter
Encourage practitioners to learn other skills
Appreciate clinician frustration
Offer moral support
Recognize or affirm the limits of the team to influence health
Summarize the differences in perspectives and recommendations that may be challenging
Clarify the roles of the obligation to benefit patients versus the duty to protect
Help interpret a patient’s capacity to make decisions or an inability to assess capacity in decision-making

26. QUESTIONS?