Caring for the ‘Difficult Patient’: Ethical Issues When Patients Do Not Adhere to Medical Advice

1. 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. 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. The ‘ethical’ truth:

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 1What 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 2What 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 3What 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 4What 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. ethos techné praxis Provide Practical Wisdom Prevent Default Decisions Promote Freedom Minimize Moral Distress Ensure Integrity Reduce Moral Hazards

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

14. Foundational Questions…

15. Moral Hazards inDifficult 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

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

20. 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? • If no, what’s your BATNA*? • Do you have a bond with this patient? • If no, how can you bridge the gap? *BATNA = Best Alternative To No [or Negotiated] Agreement”

21. Benefit versus No Harm Beneficence Nonmaleficence 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 • Obligations… • to support and provide medical goods (benefits) • to protect others from harm

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.)

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?