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Rebecca Fromme, Ph.D. McGuire VAMC Geriatrics and Extended Care.

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Presentation on theme: "Rebecca Fromme, Ph.D. McGuire VAMC Geriatrics and Extended Care."— Presentation transcript:

1 Rebecca Fromme, Ph.D. McGuire VAMC Geriatrics and Extended Care

2  64 year-old, married Vietnam veteran  100% SC: PTSD, Impaired Vision, Diabetes, Loss of Lower Leg  Cognitively intact  Dialysis 3 days per week  Long history of poor compliance, CLC admission in 2009 for amputation and rehab of right lower limb, recent readmission for wound on other foot

3  Frequently refused dialysis, and when he did go, he only stayed for 1-2 hours (rather than full 4 hour session)  Frequently refused meds, refused blood sugar checks  Very poor food choices, would not follow diabetic diet, made it impossible to keep his blood sugars level  Refused care, then later demanded a shower “RIGHT NOW”  Verbally and physically threatening to staff, particularly nurses  Caught smoking in his room  Used foul language when he did not get immediate attention  Refused to attend PT so that he could be strengthened and fitted for prosthesis, but demanded the prosthesis anyway

4  Extensive diabetic education from Geriatricians, Dietician, NP, Nursing Staff, RT, and OT on multiple occasions  Pleading  Encouraging  Nagging  Scolding  Escorting to cafeteria to make healthier choices  Psychiatry Consult  Increasing ALL OF THE ABOVE

5  Challenging behaviors continued  Medical providers and staff became more concerned, frustrated, worried, guilty  Staff decided to regroup, try something else…..

6  Longstanding pattern of maladaptive relationships  Poor ability to understand others’ point of view  Lack of empathy on how his behaviors affect others  Poor recognition of his own responsibility in current circumstances  Fixed way of responding to staff, regardless of the situation  Emotional dysregulation  Manipulative behaviors  Unhappiness  Socially maladaptive/Complete disregard for unit rules

7  Psychology met with treatment team to inform them of results of cognitive evaluation- Behaviors not a result of cognitive impairment, inability to remember the rules, or inability to remember what he should be eating  Mr. W’s food choices are conscious choices, and he has right to make them even if we don’t agree- PATIENT-CENTERED CARE  Nagging, pleading, scolding only serves to trigger control issues and increases resistant behaviors  Instead, praise, encourage, reinforce those times he does behave appropriately- HARM REDUCTION  Do not engage in a “battle of the wills”  Understand that not all situations can be “fixed”- CARING NOT CURING  Practice de-escalating conflicts before they occur

8  Check yourself first– remember not to take it personally. It’s about the situation, not you  Deal with the person’s emotions first. Problem solving cannot occur if the person is fuming!  When hostility is rising, diffuse it early with an empathic statement  Most people will DRASTICALLY de-escalate once the emotion has been recognized and they have a minute to vent  Speak to the other person as if he/she IS NOT upset  Inquire, don’t interrogate  Set limits, if necessary. Return later when patient is calmer.

9 Instead of:  “That’s never going to work”  “That’s not my problem”  “I don’t work that way, I have high standards”  “I don’t have time right now” Try:  “I don’t have enough info to see how this will work”  “I don’t understand how you feel I can help in this situation”  “I have concerns about doing it this way. I’d like to suggest another way that leads to the same goals”  “I’m handling several emergencies today, but if you let me know what you need I will get to it as quickly as I possibly can”

10  Summarize the patient’s chief concerns  Interrupt less  Increase empathy, attempt to name the patient’s emotional state  “You seem quite upset. Can you help me understand what’s going on for you right now?”  Offer regular, brief summaries of what you are hearing from the patient  “What I hear from you is that……. Did I get that right?”

11  Discuss the fact that the relationship is less than ideal  Offer ways to improve care  “How do you feel about the care you are receiving from me?”  “It seems to me that we sometimes don’t work together very well.”  “You look a little confused. Would it help if I explain it again?”

12  Clarify the reason for the patient seeking care  Indicate what part the patient must play in caring for his/her health  Revise expectations if they are unrealistic (both yours and the patient’s)  “What’s your understanding of what I am recommending and how does it fit with your ideas of how to solve your problems?”  “I wish I (or a medical miracle) could solve this problem for you, but the power to make the important changes is really yours.”

13  Fewer aggressive episodes  Slightly improved compliance with dialysis through compromise  Reduced verbal abuse  Reduced staff stress  Improved patient satisfaction


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