By Stacey Kusterbeck
ED patients often are stressed, scared, and imagining the worst. For some, that results in unfortunate behavior. Patients in EDs are not infrequently impatient, critical, and even overtly insulting.
“This is dangerous when you start reacting to it personally. You lose objectivity, avoid the patient, and end up not providing the best care,” warns David Ledrick, MD, director of observation medicine at Mercy St. Vincent Medical Center in Toledo, OH.
Overworked ED nurses likely avoid going out of their way to check on an unpleasant, demanding patient. Emergency care providers may fail to see warning signs indicating the patient is deteriorating because they are looking to expedite the disposition.
“The less time you spend with the patient, the less likely you are to get a good history,” Ledrick says. “It’s hard to be an advocate for somebody who gives you one-word answers, fails to make eye contact, rolls their eyes at you, and complains.”
Patients who behave in this manner could be at risk for a missed diagnosis caused by poor communication with the treatment team. “They may be so difficult to tolerate that they receive less attention and nursing care than they would have otherwise,” Ledrick advises.
The best approach, says Ledrick, is to “recognize the risks with these types of patients and mitigate them.” Here are some approaches to mitigate risks when patients are behaving rudely:
• Document objectively. For emergency care providers, it is tempting to turn to the medical record to vent frustration about a patient who is behaving in a disrespectful manner. However, documentation should focus on the patient’s care. “You may spend a line or two stating that the patient was behaving in a hostile manner, giving evasive answers, or that they were clearly upset,” Ledrick says.
However, the chart should convey that the clinical team was focused on providing quality care. “The internet is filled with examples of unfortunate charting, usually from the files of malpractice cases that did not go the way of the defense,” Ledrick adds.
• Do not take insulting or rude behavior personally. “It makes no sense to allow an insult from somebody you just met and who’s going to be out of your life in just a couple hours to cause you any personal distress,” Ledrick says.
Ledrick has been on the receiving end of insults of all sorts, including accusations that he is uncaring, stupid, and incompetent. One patient alleged Ledrick did not provide good care because the patient did not present with insurance. Patients routinely insult emergency care providers’ personal appearance or level of expertise.
For medical providers, it can be helpful to bear in mind that many of those patients are reacting to the situation at hand. “Don’t assume that they always behave this way,” Ledrick offers.
• Enlist the help of family and friends. “Don’t ignore the other people in the room,” Ledrick says.
Often, individuals accompanying the patient can offer additional information that puts the patient’s behavior in perspective. Emergency care providers can make it clear that everyone in the ED is working in the best interest of the patient.
If the patient is alone, sometimes there is a relative to call and put on speakerphone. “From a risk management standpoint, the story matters. And the only story the family will hear will be that of your pissed-off patient if you don’t include the family in the conversation,” Ledrick cautions.
In that situation, emergency care providers should document the person’s response (e.g., “Spoke with family on speakerphone while at patient’s bedside, family agreed with care plan.”).
• Make a personal connection with the patient. Finding something in common with a seemingly “difficult” patient, unrelated to the ED visit, can turn things around dramatically.
Recently, ED nurses expressed frustration with an irate patient who repeatedly demanded to know when he was going to be discharged. When Ledrick went to the room and noticed the patient’s Steelers cap, he mentioned that his parents grew up in Pittsburgh. The man visibly relaxed and expressed concern about needing to meet his children at the school bus stop.
Within a few minutes, nurses gathered a correct phone number for the patient so the man could be discharged before the pending blood work returned. “He was able to get his kids home safely; as it turned out, his labs were negative anyway,” Ledrick remembers. “Literally 80 seconds of a personal story turned a fairly confrontational encounter around.”
Patients who behave in this manner could be at risk for a missed diagnosis caused by poor communication with the treatment team. They may be so difficult to tolerate that they receive less attention and nursing care than they would have otherwise. The best approach is to recognize the risks with these types of patients and mitigate them.
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