You may be able to overcome some hostility in a violent patient if you are able to:

Quick guide

• Focus on listening to your patient and try to understand why they are behaving this way
• Set boundaries of acceptable behaviour
• Consider ending the relationship if these steps are not effective

How to deal with difficult patients and families

Managing difficult patients or family members is a part of medical practice. It is important to acknowledge that often patients are upset, angry or demanding for a valid reason and that they have valid concerns. Demonstrating understanding and effective communication are essential. There are some key steps to remember that may assist you with these issues.

Recognise the issue

The first skill in dealing with difficult patients and families is to recognise a difficult situation.

Is it the patient?

With most people labelled as ‘difficult’ there is something else going on. It may be the stress of the illness or other stressors in their lives. These patients may be angry, distressed, scared, have unrealistic treatment expectations or be particularly demanding. Sometimes these behaviours may be the result of previous bad experiences. It is beneficial to explore these factors to try to identify and address the underlying issues.

Is it you?

Everybody has bad days. Our own stress, tiredness or hunger may play a part and it is important to take a moment to reflect on our own behaviour. Things are rarely completely one sided when they escalate out of control. To prevent escalation, remain non-confrontational, maintain your cool and don’t get caught up in trying to win an argument.

Is it the system?

Sometimes things out of your control can add to the situation, such as complications with billing procedures or long wait times at the surgery or in the hospital. You can acknowledge the issue and empathise with the patient. Something as simple as apologising for a long wait time might be all that is needed to take the edge off the patient’s anger.

What to do?

Listening is the best thing you can do

If a patient or family member becomes difficult the best thing you can do is to actively listen to their concerns. It is important to give them the opportunity to have their say and for you to empathise with them and acknowledge that they have been heard.

Ask questions

Use reflective listening skills to check that you understand the patient’s concerns. You need to understand what the issues are to address them. Once you have listened to the patient’s concerns, ask questions to clarify any issues and to ensure you comprehend all the relevant concerns. You could say “Have I understood everything correctly?” or “Is there anything I have missed?”.

Angry patients

It may be appropriate to allow patients to vent their anger and for you to acknowledge it: “I can see that you are very angry about this”. Their feelings can be acknowledged without you necessarily agreeing with what they are saying. In some situations, you may wish to validate their anger if appropriate: “Understandably you are angry. This is a very frustrating situation you are in”.

In addition:

• keep calm, use a neutral tone and adopt an open body posture
• avoid becoming defensive or taking comments personally. Seek to smooth the situation over rather than demanding the patient behave.

Violent patients

Your safety and the safety of those around you is the most important issue when confronted by a violent person. To defuse a violent situation:

• remain calm
• reassure and acknowledge any grievances
• provide them with an opportunity to explain
• maintain eye contact
• keep a safe distance, positioning yourself between the patient and an exit
• get help or leave the room if you are feeling unsafe

Manipulative patients

You can feel manipulated by patients in a variety of ways. Manipulative patients threaten, cajole, cry or use guilt in an attempt to get their own way. These patients are difficult to talk to. They can be entrenched in their version of events and will not budge from their beliefs. Be careful not to compromise your care by giving in to unreasonable demands. A manipulative patient will do all they can to convince you to do what they demand, for example, threatening to issue a complaint against you if you do not prescribe a particular drug or give them special treatment.

The key with these patients is how you react once you realise you are being manipulated. You need to:

• remain firm
• attempt to understand the patient’s expectations and try to separate those from their behaviour
• try to help the patient within appropriate boundaries
• realise that sometimes you need to say “no”
• seek help from a colleague or refer the patient to another practitioner.

Difficult families

Challenging encounters with your patient’s family and friends need to be carefully managed. These encounters can be the result of their stress or what they consider to be a previous lack of communication or mishandling of the patient’s care. Communication is essential to get to the heart of the issue. The appropriate approach is to engage with the family more and keep them updated. However, always remember your obligations to your patient with regards to their privacy and remember to seek your patient’s consent before speaking to their family or friends. In an emergency you are able to convey information to the family without the patient’s consent.

Set boundaries

While empathy and understanding are imperative, it is also necessary to establish boundaries and be firm about these with your patient. Boundaries establish what behaviour you find acceptable or unacceptable within your practice or at the hospital. Seek your patient’s acknowledgment and agreement on these boundaries. You may want to establish a treatment plan with the patient where you agree what is acceptable in terms of behaviour, such as “you will not telephone me after 8pm but rather call an ambulance if it is an emergency”, or “you agree not to use profanity when speaking to me”, or “I do not prescribe drugs of addiction”. Offering the patient choices in treatment, using a shared decision-making model, may also improve the patient’s engagement with their care and your relationship.

Know your limits

It is important to have some insight into your strengths and weaknesses when it comes to dealing with difficult patients or families.

Think about whether you have the right mix of personality and skills to effectively deal with a difficult patient or whether you may need to let someone else who is more familiar or sympathetic with the patient take over. Don’t forget to work as a team with other health practitioners at the hospital or your practice.

If it gets to a point where the patient becomes physically or verbally abusive, it’s time to step back. Tell them that they have overstepped the boundary and that their behavior has become unacceptable, and then initiate your security protocol.

Accept that some doctor-patient relationships cannot continue

Consider whether you can continue working with the patient if the relationship has broken down and you believe the patient does not trust your clinical judgment. It may be in the patient’s or your best interests that you do not continue looking after them.

If necessary, seek advice from Avant on how to appropriately end the doctor–patient relationship. It is important this is done in the correct manner to avoid alienating the patient, which could lead to a possible complaint against you. Avant has further information here: link avant.org.au/Resources/Public/20140903-How-to-end-the-dr-pt-relationship/

Documentation

Take particular care to document events involving confrontations and discussions with a difficult patient or family member. Your summary of the interaction should be factual and objective. You may want to step back and calm down before you make an entry in the patient’s records.

Support

Managing difficult patients and their families can be stressful and draining. Prioritise your own wellbeing by paying attention to work-life balance, engaging in hobbies and exercise, and taking care of your relationships so you are in the best position to manage stressful interactions with your patients. It is also valuable to seek support and help from your colleagues.

If you have a challenging interaction with a patient, take some time to think about the events and your response, and reflect on the outcome and anything you may have learnt to help you with similar interactions in the future.

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