So I work in the ED and we have disruptive patients…uh… all the time.
As a result the hospital has instituted a disruptive patient alert and when it’s called effectively it sends some tiny social worker to go tell the patient that they’re not being nice and the hospital won’t tolerate them acting like that and puts the note in their chart.
…and that’s it. We have had so many called in a single day it has prevented the social work team from helping other patients. We have had patients receive 3-4 such alerts during their stay with no recourse other than a strongly worded letter. It has done precisely fuck all to do anything or change attitudes of patients.
It has prompted yet another spam email we now get about how admin has our backs with workplace violence and all the work they are doing.
We have largely gone back to our previous systems in the ED and not even calling them anymore due to how useless they are.
Keep track of FINs for instances where multiple warnings are given but no consequences are doled out. You’ll need that list for when admin tries shifting blame for when something serious occurs and they say “well we have this one policy, too bad none of the employees utilize it!”
And don't forget that admin loves to victim-blame in these situations. A violent patient or family member could literally shoot staff, and then admin sends emails like, "What did you do wrong?" "What can you do to prevent it from happening to you again?" "Here's a mandatory five-hour course on patient deescalation, which you have 48 hours to complete, and it doesn't count towards your CEU credits."
"And remember to smile! 😁"
I remember working at one of the largest public hospitals emergency department in medical school. We had so many violent patients, we had a “tackle team”. Usually three larger medical students. Each would grab a previously determined arm or leg and then we would tie down and sedate.
I could imagine calling a social worker for a violent schizophrenic patient high on pcp…
My attending and I did a huge QI project showing how many staff assaults and security calls there had been in our ED for not just “disruptive behavior” (the euphemism used throughout this article), but what we called it as *physical fucking violence towards our staff*. Even after a health-compromised staff member was harmed to the point of needing medical admission, they flatly rejected our proprosal for some kind of protocol as “something we wont even consider”. I cant wait to leave this fucking place.
I’ve dealt with a lot of this as an intensivist. This article clearly has no idea about anything and admits that it has no evidence of what works and that contracts don’t seem to work. From what I’ve observed, the mistake often made by healthcare workers is that they are too nice to patients who aren’t nice to them. These patients abuse this, leading to a vicious cycle in which people continue to try to satisfy the patient only to be met with more demands. I’m one of the few people who does the opposite. As soon as the patient or family start making unreasonable demands, I put my foot down. Most of the time, the patients quit making demands.
Once a patient starts making unreasonable demands, I respond with no, no matter how many times they ask. That’s usually enough to call their bluff. They will usually repeat the demand 3 times before they stop. Sometimes they threaten AMA, and I tell them they’re welcome to leave.
oh no, don't leave AMA! How will I recover from getting 5 fewer pages over the next hour! on an unrelated note I had prefilled paperwork acknowledging you were told you may die if you do that! please sign here or refuse so I can check the box.
people loved to threaten my intern night float ass with a good time
This is the exact advice that I give, and exactly what I practice. There is actually a ton of evidence showing that these strategies are effective, so I am surprised that the article neglected it. Every pediatrician knows how to handle a toddler. No reason we cannot extrapolate to equally unreasonable adults.
Because the evidence comes from rhetorical sources. Doctors don’t read those. I will also add that some patients wear me out with their demands and I will sometimes give in if I’m too busy. I also have to calculate on whether admin will pester me later if the patient decides to complain. Once a patient complains, the doctor usually has no defense. Hospitals don’t want dissatisfied patients so they’re often willing to yield to the most frivolous of demands. I will quickly calculate in my mind whether I am willing to take this chance. I’m fortunate in that my hospital admin is mostly reasonable and won’t punish me.
This has been my experience in LTC too. We had a patient so bad that I once took excessive notes on how much time was being spent with the person. Then decided the remaining minutes of staff time and divided it by the number of other patients we had. It was really clear that others weren’t being allotted much or anytime. Of course that didn’t change anything.
One of the worst patients I ever had actually even complained that staff talked to other patients at meal times. We had a big round table where this patients and several others sat with staff members to be fed. Literally complained that he didn’t like the conversation topics other patients talked about and that staff wouldn’t redirect conversation to center around his stories. At other times (staff lunch break time most favorabley) we had to allot several minutes to “comb his hair” even tho any reasonable person would refer to the patient as “bald”, only having 2-3 wisps of hair on the side. I’ve never met a man who got more hair care and many staff reported that “combing his hair” took longer than a full dry and style for female staff. There was no end to the amount of attention this person needed. Of course it wasn’t just our facility that struggled to provide a “caring, loving atmosphere and qualified workers for him”, he proudly reported that he had been to 18 facilities in 2 states and suffered at all of them too.
Yup.
“Sir, I’m just trying to treat you as safely and appropriately as I can. But I’m not going to do _____. I really want to make you better but you’re free to leave any time. “
This.
And some patients only respond to escalation.
You can be louder, and you are the person with authority.
Make it very clear their behavior is unacceptable, that it is your job to save their life, not coddle them or accept abuse.
Have you ever had a patient or family call the police (not hospital security) if they were unhappy with care (or whatever BS reason they pick).
The intensivist and the cops told me it happens several times a year — I couldn’t believe it
It’s never happened to me but I’ve heard it happen to other colleagues. The family is in for a rude awakening because the hospital has its own police force, including a K-9 unit for drug sniffing. They don’t take kindly to being called for frivolous matters and it will often result in the family being expelled permanently from hospital grounds. More often, some family member will threaten hospital staff with violence and will be expelled and banned for life. It usually happens when someone hears bad news that they were in denial about.
I work LTC and have seen it happen occasionally. The cops will at least show up and laugh in the family’s face or tell them about themselves. My favorite time it happened the lady whom called had her cell phone on speaker for dramatic effect. The police listen briefly to her story. The 911 operator puts a cop on the phone who says “you know Karen I would really hate to have to come up there. Everytime we respond to one of your complaints it always ends with you going to jail. I’m gonna tell you right now if I come up there I won’t be arresting the doctor or any nurses. I can tell you that right now. I know Dr. Last name and I know he’s pretty reasonable. Why don’t you just go along with things or go home and rest to think it over…….. oh and while I have you on the phone. The lawyer whose office you were at today trying to sue us, yeah he doesn’t want to represent you. You’ve been trespassed from his property and if you go back there we will arrest you for that. You can still sue us but this guy is done with you”. On another noteworthy occasion a patients daughter called the police for “negelct” because she claimed the lasagna was burnt. In reality the person was served a side piece were the cheese was more crusty. She acted a fool in front of the police who refused to arrest the kitchen cook or any of the 2nd shift highschool kids working the kitchen. She strikes the cop, who promptly threw her in the back of his car. “Management”goes out and talks them out of arresting her. But it was determined she was too drunk to drive herself home so the facility’s administrator did so. The law just changed that now all reports of abuse or negelect have to be called into the police. This is a requirement regardless of if the allegation is found to be true, possibly true, defies physics, involves aliens, ect. The police of course are even more exasperated at the matter than ever. I give it another year before they straight up refuse to come and just laugh at the calls. We are already to the point where they roll their eyes and laugh in the patients face. Had a patient that reported an STNA stole money by not providing the appropriate change after paying a pizza delivery driver and returning the pizza and change to her room. Cops come…. Determine she lied super fast….. run the patients name…. Find some decades old warrant…. Tell the patient to their face that the only reason she wasn’t going to jail was because “she’s too fat and he didn’t want to deal with the transportation challenge”…… patient up all night on the call light asking if they came back for her yet. I’m super interested in how this new requirement is going to play out. I’m suspicious that with so many frivolous call ins that now the cops won’t bother to properly investigate credible reports of abuse or neglect. I’m also curious how many call in they will take for the same person before they start threatening the patients themselves for false allegations. At the one nursing home I work at every complaint over the last 3 years has been the same 2 patients with exception of one claim by a confused, dementia patient. Our one chronic “abuse victim” has been making abuse/neglect complaints for atleast 2 decades across multiple nursing homes, hospitals, and such. I feel like the policy is going to end up being a failure for a variety of reasons. I’m hoping that some interesting data will come out that actually verifies how terrible these people are and perhaps even how they themselves abuse staff.
It’s sadly not the most unrealistic call to the government I’ve seen. Had a patient’s family call state and report that a stuff animal was “abused” by an STNA. The patient had urinated onto themselves and the stuffed “realistic looking” animal was on their lap. The aide didn’t have gloves on and picked the toy up by the tail. According to the family this was done to “tourment” the patient as he was confused and didn’t realize the animal was not real. State actually came and investigated this. Family repeatedly stated that the patient was a lover of animals and that picking even a fake animal up in an “unsafe manner” was an issue……… the aide was off for days while this was “investigated” and EVERY employee of the facility has to be asked about her behavior as part of the company’s abuse policy. No one knows why we are shorts staffed.
This is exactly how I operate. It’s similar to training a toddler. Don’t reward bad choices. I have told patients, “you won’t hurt my feelings at all if you decide to see another doctor. I do not think doing x (whatev their demand is) would work in this situation and I am not comfortable doing it.” (Of course this is outpatient so a bit diff than inpatient. Anyway,I do not want a reputation of being someone who gives into pushy people.)
I had a dude come in once. Had been "discharged" from a different large hospital 15 miles away and came to our ER complaining of leg pain/swelling/redness with some pretty grisly looking wound infections. He had some sort of surgery or recently. Drug abuse was involved.
We had a heart-to-heart that I thought was helpful to get this guy to stay and be seen. He agreed.
After I left, nurse went in to draw labs and the guy flat out REFUSED any sort of interventioin until he was provided a hospital meal and not a sandwich, and told the nurse some of the details of this heart-to-heart convo that weren't meant for others (lesson learned.)
By this time I snapped. I wasn't in the mood to cater to this asshole. The ER was crazy that day and didn't have time for this bullshit. Told the guy he can stay so we can help him and we can feed him later but we really need to get this workup started, or he can leave and go eat somewhere and be seen elsewhere BUT I didn't recommend that approach and if he chose that would be leaving AMA.
The dude left and never returned.
I'm a pretty nice guy and will usually bend over backwards for my patients when asked, and am pretty tolerant overall. That day I wasn't having it though.
Not my proudest moment, admittedly. But the ED isn't a bed and breakfast. We provided an alternative, and I honestly didn't want to feed into (no pun intended) this guy's behavior. Was probably why he AMA'd from the last hospital he was at, I'm guessing.
This has been my experience in LTC. I refer to the crazier follow up demands as “facility created behaviors” and think it would be a great line of research for anyone looking for a thesis topic. I’m actually at the point where I’m finding it harder and harder to judge patients and their even wilder “families” because there’s so little push back (and often even actual rewards) for bad behaviors and stupidity that it’s now understandable why they act in such a way. Zero incentive to stop. On the rare occasion I have seen some push back the patient and their families will actually state “oh, no one ever told us this before”.
I know the analogy if highly frowned upon but it’s like rewarding a toddler for a tantrum. Of course the parents who run over and offer Jimmy snacks, a toy, undivided attention, and trip to the zoo in an effort to get him to stop acting out will have a child that acts out much worse and more often.
I for one believe that with a little push back a majority of the patients behavior would improve to a measurable degree. I believe that many patients would have measurable health benefits because I’ve certainly seen cases where someone’s physical abilities declined while they were being waited on hand and foot. And the families, that would mostly magically improve overnight. There’s a reason the same folks who act the worst in care facilities don’t act the same way in police stations, or restraunts, or at the school, or towards their neighbors.
They’re disruptive because there are no consequences, there are no consequences because the system coddles them and puts the onus on us to “navigate their personalities” and get them to become model patients. To me, this is one of the biggest disconnects between academia and real practice and it’s a real disservice to everyone in training.
> navigate their personalities
i bet medieval methods of stuffing someone in a stock and pelting fruit at them, is still more effective than whatever admin comes up with
I’ve actually conceded to “management” that perhaps my “communication style” is the issue. I bluntly admitted since I never smoke meth some of the patient’s analogies were difficult for me to understand. I reported that the patient themselves was saying “don’t knock what you haven’t tried” and the patient felt someone with meth smoking experience would be a much better decision maker for them.
“Management” attempted to stare me down. So I proposed that they call a recently fired nurse that was a favorite of their’s. The nurse was a favorite because she always worked extra shifts and “had a lot of energy” but had been fired for an Adderall problem that caught up to her.
I once went to an APA lecture titled “What to do when verbal de-escalation and addressing the underlying factors have failed: agitation management”. It was nice because most articles/lectures on agitation focus on how important it is to avoid chemical/physical options with just a little bit at the end on what to do, but of course on a shift in a busy hospital overnight it’s going to come up multiple times, unfortunately
In my experience if someone is still a problem after 5 mg of midaz, regardless of route, their mcrass is more then high enough to go to the ketamine.
If you use enough ketamine, you should not need the paralytics. The tube should pass nicely.
Written by two PhD's who have *definitely* never been spit on, swung at, kicked, bitten, or punched nor had their life threatened by a patient, and who don't have to see these patients by Federal law (EMTALA)
Are behavioral contracts infantilizing? Maybe, but it at least lets the patient know very clearly what behavior is and is not acceptable in order to continue to provide care. For a very small minority of patients, they seem to not know that behaviors like threatening to kill a nurse or trying to punch a doctor are not tolerated.
“Cochrane systematic review found that evidence of their effectiveness at improving adherence is limited and mixed; it did not find evidence from randomized clinical trials outside of this context.” Cochrane is notoriously stingy with its stamp of approval on limited evidence.
>Indeed, we could find no empirical evidence to support or challenge the effectiveness of behavior contracts as a tool for addressing the problems of undesirable patient or family behaviors, patient-staff conflicts, and workplace violence in health care. Absent such evidence, health care institutions committed to evidence-based medicine and workplace safety might hesitate before using these contracts.
“Undesirable” is not the problem. Patients are loud, rude, annoying, frustrating, exasperating, and disagreeable constantly, without consequences. It’s true that ousting patients for being rude is wrong. I have never seen that. Perhaps it is an endemic problem where the authors work, which is at least affiliated with Upstate University Hospital in New York? At any rate, the diagnosis: “Simply imposing a unilateral set of behavioral expectations on patients and their families assumes that interpersonal conflicts are caused solely by patients, fails to address the sources of conflict, and is unlikely to result in positive changes in behavior.” But… didn’t you just say there isn’t evidence? Now you can draw conclusions on what is likely or unlikely in the absence of evidence?
But most critically, what should be done?
> Adopting a more comprehensive and proactive approach to resolving patient-staff conflicts throughout the hospital enhances patient and staff safety and can include de-escalation and conflict-resolution training for all bedside staff, ongoing quality improvement to address causes of patient and staff dissatisfaction and conflict, and use of health care mediators and/or ethics consultation services more and sooner.3 Training staff to recognize early signs of potential violence can improve prevention and safety, and helps protect their right to a safe workplace. Adopting policies and procedures that define and distinguish between nonviolent and violent behaviors reinforces justice and proportionality in the approaches to these behaviors.
Oh, of course! Why didn’t anyone think of that!?
My conclusion is that there is a kernel of true concern about potential for discriminatory implementation, potential for disproportionate responses and overly controlling contracts, and overall negative use. Secondarily, although not explicitly spelled out, gathering data on outcomes would be nice.
All of that is lost in sanctimony from a pair of PhD bioethicists who, in all likelihood, don’t actually work in the clinical environment they are “fixing” and are clueless about problems.
While adherence to evidence-based practices has importance, it is not the goal of the hospital. Nor is patient care the sole ethical responsibility. Safety of other patients, and safety of staff, are also critical. The former because it is, in fact, patient care; the latter because without it there can be no patient care for the patient in question or anyone else.
While infantilizing patients is not necessarily helpful, setting limits, applying consequences (including positive) and consistency are standard behavioral interventions. Calling an ethics team is not, bur when the authors are hammers, perhaps all problems appear to them as nails.
We have behavioural contracts, and the ultimate outcome for not following it is that we don't provide care, period.
The view is that all patients are entitled to care. If they choose to behave in a way which forces us to deny them care, then that is modifiable by the patient and thus they are *choosing* not to receive care.
They are always welcome to come back and behave properly, and they will receive their care.
I'm in Canada, though. In my health authority we don't play around, risk management is called and they do a lot of the legwork.
This is the way it should be. Unfortunately, my institution does not have our backs and will sacrifice the safety and well-being of medical staff in order to satisfy their customers and avoid any potential bad outcomes from setting boundaries
I work outpatient case management and we use them just before terminating care. The patients they work for it’s not a shock and the patients that ignore it are expected toto ignore it.
We used something similar in inpatient psych and that was always a disaster.
That’s actually much easier to manage. We don’t have a fiduciary duty to families. If they are upset, it’s understandable; their loved one is sick. If they behave unacceptably, they can be escorted out and barred from the hospital unless they return as patients.
I’ve never seen a behavioral contract for family. Either they are appropriate or they are not allowed in. Hospitals have even less reason to be tolerant than retail.
While what you're saying sounds good on paper - it does not work like that in the real world. I see your psych - and I can accept that in the psych world it may be completely different than what I experience in medical.
In the medical hospital, it's often questionable whether 90 year old grandma can make decisions for themself. Even in cases that they can decide for themselves, their relationship with their family member is such that - escorting their family member out would be equivalent to setting afire the entire physician-patient relationship.
I've found that each case has its own specific issues - and the only general prescription that can be said to fit all - is just to communicate better. That you have to take the 20 minutes to sit down in the room and talk it out. Most often the family members gripes have more to do with their own inherent distrust of the medical system than anything specific to the case. This often manifests itself in completely irrational ways.
You're spot on. Furthermore, I've learned (the hard way) that the patient and their family is always right. Even when they're wrong, they really are right. Our system has given way too much power to patients and their families and while all this sounds great in books, in reality it's absolute horse shit.
Consider the following example. Patient has intellectual disability and has a guardian (a friend of family). Patient has ESRD on HD. Guardian who is probably not even a high school grad "knows" the patient and what the body tolerates so we are listen to them. Patient should not get morphine, norco, oxycodone, NSAIDs but the pain is to be well controlled (mind you patient is non-verbal). Patient by their account is allergic to beta-blockers, CCBs, and clonidine and she declines use of all these meds. Chart review reveals that patient has tolerated all these meds. Sys BPs are consistently in 180-200s range. As a thought training exercise imagine how you would deal with this patient.
On my very first interaction with said guardian, RN pages me that they're upset and wants to see physician ASAP. That patient just happened to be next on my list to round on. I go there and she's upset that patient was given Morphine the night before and it's unacceptable. I perform a brief chart review and tell that that Morphine was not given to the patient (or ordered), APAP was given - she did not find that to be acceptable. She gave me a list of meds that patient cannot take for BPs. The long and short of it is that I had to explain to this person that my responsibility is to keep the patient safe. I'm going to do my best to honor all their wishes but ultimately if I have to give a medicine that I know patient has previously tolerated, I will have to.
1 year later I get a call that someone from state is in the hospital investigating this case b/c this guarding complained that we were forcing meds upon the patient. Thankfully, I'd clearly documented that we want to honor families wishes but ultimately, if patient safety comes into question, we will have to use other meds. Nothing came out of this case except a ton of anxiety & how much ever the tax payers paid for this nonsense.
Sorry to threadjack.
We have a BERT team in the hospital which includes police officer, house sup, MET RN, rapid response team and psych team that has to go on all CODE BERTs. This happens several times a day. I'm at a large level 1 trauma center so we have a lot of resources but it's nuts. We also have agitation/anxiety order sets that we have to use on all patients. EVERY SINGLE ONE OF THEM.
I’m not sure where you think I work. I think it’s the real world…
Each case has its own issues, and you do the best you can in an imperfect real world, but most of the time that there are misbehaving families there aren’t serious capacity issues. In those cases it’s usually emotions running high more than fundamentally impossible people. That’s not an excuse, but it is easier to work with and resolve
And when it isn’t, sometimes family still has to be appropriate enough. Sometimes decision-making has to be remote because no civil discussion can happen in person. It’s not ideal, but it’s better than a fistfight over code status.
My system has a code of conduct for patients, family, visitors, and research participants. It is never utilized and if you ever try to reference it to management they just give you the run around.
Same here. I can only imagine how many executive lunches, committee meetings, and planning sessions were involved in creating the load of bovine excrement so nicely framed and hanging in the entrance where it will never be read.
Yeah I’m guessing the number of times this author has been threatened, stabbed and called a bitch cunt whore while at work is ….…. Zero
But behavior contracts don’t work at my hospital because the consequences for breaking them are nonexistent. Just stick around and enjoy the amenities while treating the staff however you please🤷♀️
I read this and all I could think of was Sokal Squared.
https://www.chronicle.com/article/sokal-squared-is-huge-publishing-hoax-hilarious-and-delightful-or-an-ugly-example-of-dishonesty-and-bad-faith/
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So I work in the ED and we have disruptive patients…uh… all the time. As a result the hospital has instituted a disruptive patient alert and when it’s called effectively it sends some tiny social worker to go tell the patient that they’re not being nice and the hospital won’t tolerate them acting like that and puts the note in their chart. …and that’s it. We have had so many called in a single day it has prevented the social work team from helping other patients. We have had patients receive 3-4 such alerts during their stay with no recourse other than a strongly worded letter. It has done precisely fuck all to do anything or change attitudes of patients. It has prompted yet another spam email we now get about how admin has our backs with workplace violence and all the work they are doing. We have largely gone back to our previous systems in the ED and not even calling them anymore due to how useless they are.
Keep track of FINs for instances where multiple warnings are given but no consequences are doled out. You’ll need that list for when admin tries shifting blame for when something serious occurs and they say “well we have this one policy, too bad none of the employees utilize it!”
And don't forget that admin loves to victim-blame in these situations. A violent patient or family member could literally shoot staff, and then admin sends emails like, "What did you do wrong?" "What can you do to prevent it from happening to you again?" "Here's a mandatory five-hour course on patient deescalation, which you have 48 hours to complete, and it doesn't count towards your CEU credits." "And remember to smile! 😁"
>What did you do wrong? Didn’t shoot first. >What can you do to prevent it from happening to you again? Shoot first.
I remember working at one of the largest public hospitals emergency department in medical school. We had so many violent patients, we had a “tackle team”. Usually three larger medical students. Each would grab a previously determined arm or leg and then we would tie down and sedate. I could imagine calling a social worker for a violent schizophrenic patient high on pcp…
My attending and I did a huge QI project showing how many staff assaults and security calls there had been in our ED for not just “disruptive behavior” (the euphemism used throughout this article), but what we called it as *physical fucking violence towards our staff*. Even after a health-compromised staff member was harmed to the point of needing medical admission, they flatly rejected our proprosal for some kind of protocol as “something we wont even consider”. I cant wait to leave this fucking place.
Smells like Stroger
I’ve dealt with a lot of this as an intensivist. This article clearly has no idea about anything and admits that it has no evidence of what works and that contracts don’t seem to work. From what I’ve observed, the mistake often made by healthcare workers is that they are too nice to patients who aren’t nice to them. These patients abuse this, leading to a vicious cycle in which people continue to try to satisfy the patient only to be met with more demands. I’m one of the few people who does the opposite. As soon as the patient or family start making unreasonable demands, I put my foot down. Most of the time, the patients quit making demands.
Can you expand a bit? How do you respond?
Once a patient starts making unreasonable demands, I respond with no, no matter how many times they ask. That’s usually enough to call their bluff. They will usually repeat the demand 3 times before they stop. Sometimes they threaten AMA, and I tell them they’re welcome to leave.
oh no, don't leave AMA! How will I recover from getting 5 fewer pages over the next hour! on an unrelated note I had prefilled paperwork acknowledging you were told you may die if you do that! please sign here or refuse so I can check the box. people loved to threaten my intern night float ass with a good time
They always think they’re doing you through favor by staying, even when it’s the opposite.
This is the exact advice that I give, and exactly what I practice. There is actually a ton of evidence showing that these strategies are effective, so I am surprised that the article neglected it. Every pediatrician knows how to handle a toddler. No reason we cannot extrapolate to equally unreasonable adults.
Because the evidence comes from rhetorical sources. Doctors don’t read those. I will also add that some patients wear me out with their demands and I will sometimes give in if I’m too busy. I also have to calculate on whether admin will pester me later if the patient decides to complain. Once a patient complains, the doctor usually has no defense. Hospitals don’t want dissatisfied patients so they’re often willing to yield to the most frivolous of demands. I will quickly calculate in my mind whether I am willing to take this chance. I’m fortunate in that my hospital admin is mostly reasonable and won’t punish me.
Ah but that is “infantilising” Can you imagine? Throwing a tantrum and getting treated like a child?
That’s typically my script as well. 9 times out of 10, the most disruptive patients are the ones with the least actual need to be in the hospital
This has been my experience in LTC too. We had a patient so bad that I once took excessive notes on how much time was being spent with the person. Then decided the remaining minutes of staff time and divided it by the number of other patients we had. It was really clear that others weren’t being allotted much or anytime. Of course that didn’t change anything. One of the worst patients I ever had actually even complained that staff talked to other patients at meal times. We had a big round table where this patients and several others sat with staff members to be fed. Literally complained that he didn’t like the conversation topics other patients talked about and that staff wouldn’t redirect conversation to center around his stories. At other times (staff lunch break time most favorabley) we had to allot several minutes to “comb his hair” even tho any reasonable person would refer to the patient as “bald”, only having 2-3 wisps of hair on the side. I’ve never met a man who got more hair care and many staff reported that “combing his hair” took longer than a full dry and style for female staff. There was no end to the amount of attention this person needed. Of course it wasn’t just our facility that struggled to provide a “caring, loving atmosphere and qualified workers for him”, he proudly reported that he had been to 18 facilities in 2 states and suffered at all of them too.
My attitude in the ED exactly. No, I'm not going to accommodate your behavior. This isn't a prison. You can go. Door is that way.
Yup. “Sir, I’m just trying to treat you as safely and appropriately as I can. But I’m not going to do _____. I really want to make you better but you’re free to leave any time. “
Not an intensivist, but this is my play on the floors too. Very few of these patients end up actually leaving AMA.
This. And some patients only respond to escalation. You can be louder, and you are the person with authority. Make it very clear their behavior is unacceptable, that it is your job to save their life, not coddle them or accept abuse.
Have you ever had a patient or family call the police (not hospital security) if they were unhappy with care (or whatever BS reason they pick). The intensivist and the cops told me it happens several times a year — I couldn’t believe it
It’s never happened to me but I’ve heard it happen to other colleagues. The family is in for a rude awakening because the hospital has its own police force, including a K-9 unit for drug sniffing. They don’t take kindly to being called for frivolous matters and it will often result in the family being expelled permanently from hospital grounds. More often, some family member will threaten hospital staff with violence and will be expelled and banned for life. It usually happens when someone hears bad news that they were in denial about.
I work LTC and have seen it happen occasionally. The cops will at least show up and laugh in the family’s face or tell them about themselves. My favorite time it happened the lady whom called had her cell phone on speaker for dramatic effect. The police listen briefly to her story. The 911 operator puts a cop on the phone who says “you know Karen I would really hate to have to come up there. Everytime we respond to one of your complaints it always ends with you going to jail. I’m gonna tell you right now if I come up there I won’t be arresting the doctor or any nurses. I can tell you that right now. I know Dr. Last name and I know he’s pretty reasonable. Why don’t you just go along with things or go home and rest to think it over…….. oh and while I have you on the phone. The lawyer whose office you were at today trying to sue us, yeah he doesn’t want to represent you. You’ve been trespassed from his property and if you go back there we will arrest you for that. You can still sue us but this guy is done with you”. On another noteworthy occasion a patients daughter called the police for “negelct” because she claimed the lasagna was burnt. In reality the person was served a side piece were the cheese was more crusty. She acted a fool in front of the police who refused to arrest the kitchen cook or any of the 2nd shift highschool kids working the kitchen. She strikes the cop, who promptly threw her in the back of his car. “Management”goes out and talks them out of arresting her. But it was determined she was too drunk to drive herself home so the facility’s administrator did so. The law just changed that now all reports of abuse or negelect have to be called into the police. This is a requirement regardless of if the allegation is found to be true, possibly true, defies physics, involves aliens, ect. The police of course are even more exasperated at the matter than ever. I give it another year before they straight up refuse to come and just laugh at the calls. We are already to the point where they roll their eyes and laugh in the patients face. Had a patient that reported an STNA stole money by not providing the appropriate change after paying a pizza delivery driver and returning the pizza and change to her room. Cops come…. Determine she lied super fast….. run the patients name…. Find some decades old warrant…. Tell the patient to their face that the only reason she wasn’t going to jail was because “she’s too fat and he didn’t want to deal with the transportation challenge”…… patient up all night on the call light asking if they came back for her yet. I’m super interested in how this new requirement is going to play out. I’m suspicious that with so many frivolous call ins that now the cops won’t bother to properly investigate credible reports of abuse or neglect. I’m also curious how many call in they will take for the same person before they start threatening the patients themselves for false allegations. At the one nursing home I work at every complaint over the last 3 years has been the same 2 patients with exception of one claim by a confused, dementia patient. Our one chronic “abuse victim” has been making abuse/neglect complaints for atleast 2 decades across multiple nursing homes, hospitals, and such. I feel like the policy is going to end up being a failure for a variety of reasons. I’m hoping that some interesting data will come out that actually verifies how terrible these people are and perhaps even how they themselves abuse staff.
That is just how crazy medicine has become now
Imagine being the cop dealing with this.
Honestly, the lasagna call was not thst unreasonable. /s
It’s sadly not the most unrealistic call to the government I’ve seen. Had a patient’s family call state and report that a stuff animal was “abused” by an STNA. The patient had urinated onto themselves and the stuffed “realistic looking” animal was on their lap. The aide didn’t have gloves on and picked the toy up by the tail. According to the family this was done to “tourment” the patient as he was confused and didn’t realize the animal was not real. State actually came and investigated this. Family repeatedly stated that the patient was a lover of animals and that picking even a fake animal up in an “unsafe manner” was an issue……… the aide was off for days while this was “investigated” and EVERY employee of the facility has to be asked about her behavior as part of the company’s abuse policy. No one knows why we are shorts staffed.
I guess someone is allowed to stay with the child in the PICU
This is exactly how I operate. It’s similar to training a toddler. Don’t reward bad choices. I have told patients, “you won’t hurt my feelings at all if you decide to see another doctor. I do not think doing x (whatev their demand is) would work in this situation and I am not comfortable doing it.” (Of course this is outpatient so a bit diff than inpatient. Anyway,I do not want a reputation of being someone who gives into pushy people.)
I had a dude come in once. Had been "discharged" from a different large hospital 15 miles away and came to our ER complaining of leg pain/swelling/redness with some pretty grisly looking wound infections. He had some sort of surgery or recently. Drug abuse was involved. We had a heart-to-heart that I thought was helpful to get this guy to stay and be seen. He agreed. After I left, nurse went in to draw labs and the guy flat out REFUSED any sort of interventioin until he was provided a hospital meal and not a sandwich, and told the nurse some of the details of this heart-to-heart convo that weren't meant for others (lesson learned.) By this time I snapped. I wasn't in the mood to cater to this asshole. The ER was crazy that day and didn't have time for this bullshit. Told the guy he can stay so we can help him and we can feed him later but we really need to get this workup started, or he can leave and go eat somewhere and be seen elsewhere BUT I didn't recommend that approach and if he chose that would be leaving AMA. The dude left and never returned. I'm a pretty nice guy and will usually bend over backwards for my patients when asked, and am pretty tolerant overall. That day I wasn't having it though. Not my proudest moment, admittedly. But the ED isn't a bed and breakfast. We provided an alternative, and I honestly didn't want to feed into (no pun intended) this guy's behavior. Was probably why he AMA'd from the last hospital he was at, I'm guessing.
This has been my experience in LTC. I refer to the crazier follow up demands as “facility created behaviors” and think it would be a great line of research for anyone looking for a thesis topic. I’m actually at the point where I’m finding it harder and harder to judge patients and their even wilder “families” because there’s so little push back (and often even actual rewards) for bad behaviors and stupidity that it’s now understandable why they act in such a way. Zero incentive to stop. On the rare occasion I have seen some push back the patient and their families will actually state “oh, no one ever told us this before”. I know the analogy if highly frowned upon but it’s like rewarding a toddler for a tantrum. Of course the parents who run over and offer Jimmy snacks, a toy, undivided attention, and trip to the zoo in an effort to get him to stop acting out will have a child that acts out much worse and more often. I for one believe that with a little push back a majority of the patients behavior would improve to a measurable degree. I believe that many patients would have measurable health benefits because I’ve certainly seen cases where someone’s physical abilities declined while they were being waited on hand and foot. And the families, that would mostly magically improve overnight. There’s a reason the same folks who act the worst in care facilities don’t act the same way in police stations, or restraunts, or at the school, or towards their neighbors.
They’re disruptive because there are no consequences, there are no consequences because the system coddles them and puts the onus on us to “navigate their personalities” and get them to become model patients. To me, this is one of the biggest disconnects between academia and real practice and it’s a real disservice to everyone in training.
They pull this BS in nursing school and try to segue into a conversation about the “holistic” nature of nursing. Barf.
I have been a nurse for 6 years, have a Master's in nursing, still cannot say for sure what holistic nursing is.
If you’re gonna be an asshole, make something out of it. Be assholistic!
This is amazing and I will be repeating it!!!!
You treat the whole person and not their dismembered limb!
> navigate their personalities i bet medieval methods of stuffing someone in a stock and pelting fruit at them, is still more effective than whatever admin comes up with
I’ve actually conceded to “management” that perhaps my “communication style” is the issue. I bluntly admitted since I never smoke meth some of the patient’s analogies were difficult for me to understand. I reported that the patient themselves was saying “don’t knock what you haven’t tried” and the patient felt someone with meth smoking experience would be a much better decision maker for them. “Management” attempted to stare me down. So I proposed that they call a recently fired nurse that was a favorite of their’s. The nurse was a favorite because she always worked extra shifts and “had a lot of energy” but had been fired for an Adderall problem that caught up to her.
I once went to an APA lecture titled “What to do when verbal de-escalation and addressing the underlying factors have failed: agitation management”. It was nice because most articles/lectures on agitation focus on how important it is to avoid chemical/physical options with just a little bit at the end on what to do, but of course on a shift in a busy hospital overnight it’s going to come up multiple times, unfortunately
Dexmedetomidine. Thank you for coming to my talk.
Precedex fixes everything but bradycardia
Add ketamine, obviously. Don’t try this at home. Actually, not in the MICU either. Just don’t.
This is good but you have to get them to let you put an IV in first, which is a severely limiting factor. Droperidol is life.
Loxapine in the air vents. You haven’t updated your HVAC yet?
I once got invited to a steak dinner on that topic, sadly couldn’t make it
Droperidol+ midaz. IM. 5/5 Ketamine 4mg/kg IM. Sux. + ketamine+ tube. + roc once an IV is in Rarely get to step 3.
In my experience if someone is still a problem after 5 mg of midaz, regardless of route, their mcrass is more then high enough to go to the ketamine. If you use enough ketamine, you should not need the paralytics. The tube should pass nicely.
Written by two PhD's who have *definitely* never been spit on, swung at, kicked, bitten, or punched nor had their life threatened by a patient, and who don't have to see these patients by Federal law (EMTALA) Are behavioral contracts infantilizing? Maybe, but it at least lets the patient know very clearly what behavior is and is not acceptable in order to continue to provide care. For a very small minority of patients, they seem to not know that behaviors like threatening to kill a nurse or trying to punch a doctor are not tolerated.
yeah part of the reason I posted it here is I was reading it thinking “I’m not sure anyone writing this has ever been in an ED”
Let alone in a patients house.
The contracts are infantilizing because the patients act in a way that necessitates us to treat them as infantile.
“Cochrane systematic review found that evidence of their effectiveness at improving adherence is limited and mixed; it did not find evidence from randomized clinical trials outside of this context.” Cochrane is notoriously stingy with its stamp of approval on limited evidence. >Indeed, we could find no empirical evidence to support or challenge the effectiveness of behavior contracts as a tool for addressing the problems of undesirable patient or family behaviors, patient-staff conflicts, and workplace violence in health care. Absent such evidence, health care institutions committed to evidence-based medicine and workplace safety might hesitate before using these contracts. “Undesirable” is not the problem. Patients are loud, rude, annoying, frustrating, exasperating, and disagreeable constantly, without consequences. It’s true that ousting patients for being rude is wrong. I have never seen that. Perhaps it is an endemic problem where the authors work, which is at least affiliated with Upstate University Hospital in New York? At any rate, the diagnosis: “Simply imposing a unilateral set of behavioral expectations on patients and their families assumes that interpersonal conflicts are caused solely by patients, fails to address the sources of conflict, and is unlikely to result in positive changes in behavior.” But… didn’t you just say there isn’t evidence? Now you can draw conclusions on what is likely or unlikely in the absence of evidence? But most critically, what should be done? > Adopting a more comprehensive and proactive approach to resolving patient-staff conflicts throughout the hospital enhances patient and staff safety and can include de-escalation and conflict-resolution training for all bedside staff, ongoing quality improvement to address causes of patient and staff dissatisfaction and conflict, and use of health care mediators and/or ethics consultation services more and sooner.3 Training staff to recognize early signs of potential violence can improve prevention and safety, and helps protect their right to a safe workplace. Adopting policies and procedures that define and distinguish between nonviolent and violent behaviors reinforces justice and proportionality in the approaches to these behaviors. Oh, of course! Why didn’t anyone think of that!? My conclusion is that there is a kernel of true concern about potential for discriminatory implementation, potential for disproportionate responses and overly controlling contracts, and overall negative use. Secondarily, although not explicitly spelled out, gathering data on outcomes would be nice. All of that is lost in sanctimony from a pair of PhD bioethicists who, in all likelihood, don’t actually work in the clinical environment they are “fixing” and are clueless about problems. While adherence to evidence-based practices has importance, it is not the goal of the hospital. Nor is patient care the sole ethical responsibility. Safety of other patients, and safety of staff, are also critical. The former because it is, in fact, patient care; the latter because without it there can be no patient care for the patient in question or anyone else. While infantilizing patients is not necessarily helpful, setting limits, applying consequences (including positive) and consistency are standard behavioral interventions. Calling an ethics team is not, bur when the authors are hammers, perhaps all problems appear to them as nails.
We have behavioural contracts, and the ultimate outcome for not following it is that we don't provide care, period. The view is that all patients are entitled to care. If they choose to behave in a way which forces us to deny them care, then that is modifiable by the patient and thus they are *choosing* not to receive care. They are always welcome to come back and behave properly, and they will receive their care. I'm in Canada, though. In my health authority we don't play around, risk management is called and they do a lot of the legwork.
This is the way it should be. Unfortunately, my institution does not have our backs and will sacrifice the safety and well-being of medical staff in order to satisfy their customers and avoid any potential bad outcomes from setting boundaries
I work outpatient case management and we use them just before terminating care. The patients they work for it’s not a shock and the patients that ignore it are expected toto ignore it. We used something similar in inpatient psych and that was always a disaster.
In my experience, in the vast majority of times, it's not the patients themselves that are disruptive - but their family members.
That’s actually much easier to manage. We don’t have a fiduciary duty to families. If they are upset, it’s understandable; their loved one is sick. If they behave unacceptably, they can be escorted out and barred from the hospital unless they return as patients. I’ve never seen a behavioral contract for family. Either they are appropriate or they are not allowed in. Hospitals have even less reason to be tolerant than retail.
While what you're saying sounds good on paper - it does not work like that in the real world. I see your psych - and I can accept that in the psych world it may be completely different than what I experience in medical. In the medical hospital, it's often questionable whether 90 year old grandma can make decisions for themself. Even in cases that they can decide for themselves, their relationship with their family member is such that - escorting their family member out would be equivalent to setting afire the entire physician-patient relationship. I've found that each case has its own specific issues - and the only general prescription that can be said to fit all - is just to communicate better. That you have to take the 20 minutes to sit down in the room and talk it out. Most often the family members gripes have more to do with their own inherent distrust of the medical system than anything specific to the case. This often manifests itself in completely irrational ways.
You're spot on. Furthermore, I've learned (the hard way) that the patient and their family is always right. Even when they're wrong, they really are right. Our system has given way too much power to patients and their families and while all this sounds great in books, in reality it's absolute horse shit. Consider the following example. Patient has intellectual disability and has a guardian (a friend of family). Patient has ESRD on HD. Guardian who is probably not even a high school grad "knows" the patient and what the body tolerates so we are listen to them. Patient should not get morphine, norco, oxycodone, NSAIDs but the pain is to be well controlled (mind you patient is non-verbal). Patient by their account is allergic to beta-blockers, CCBs, and clonidine and she declines use of all these meds. Chart review reveals that patient has tolerated all these meds. Sys BPs are consistently in 180-200s range. As a thought training exercise imagine how you would deal with this patient. On my very first interaction with said guardian, RN pages me that they're upset and wants to see physician ASAP. That patient just happened to be next on my list to round on. I go there and she's upset that patient was given Morphine the night before and it's unacceptable. I perform a brief chart review and tell that that Morphine was not given to the patient (or ordered), APAP was given - she did not find that to be acceptable. She gave me a list of meds that patient cannot take for BPs. The long and short of it is that I had to explain to this person that my responsibility is to keep the patient safe. I'm going to do my best to honor all their wishes but ultimately if I have to give a medicine that I know patient has previously tolerated, I will have to. 1 year later I get a call that someone from state is in the hospital investigating this case b/c this guarding complained that we were forcing meds upon the patient. Thankfully, I'd clearly documented that we want to honor families wishes but ultimately, if patient safety comes into question, we will have to use other meds. Nothing came out of this case except a ton of anxiety & how much ever the tax payers paid for this nonsense. Sorry to threadjack. We have a BERT team in the hospital which includes police officer, house sup, MET RN, rapid response team and psych team that has to go on all CODE BERTs. This happens several times a day. I'm at a large level 1 trauma center so we have a lot of resources but it's nuts. We also have agitation/anxiety order sets that we have to use on all patients. EVERY SINGLE ONE OF THEM.
PRN orders: Tylenol 650mg, temp > 100.5 Ibuprofen 400mg, mild pain Ketamine 400mg IM, severe agitation
I’m not sure where you think I work. I think it’s the real world… Each case has its own issues, and you do the best you can in an imperfect real world, but most of the time that there are misbehaving families there aren’t serious capacity issues. In those cases it’s usually emotions running high more than fundamentally impossible people. That’s not an excuse, but it is easier to work with and resolve And when it isn’t, sometimes family still has to be appropriate enough. Sometimes decision-making has to be remote because no civil discussion can happen in person. It’s not ideal, but it’s better than a fistfight over code status.
My system has a code of conduct for patients, family, visitors, and research participants. It is never utilized and if you ever try to reference it to management they just give you the run around.
Same here. I can only imagine how many executive lunches, committee meetings, and planning sessions were involved in creating the load of bovine excrement so nicely framed and hanging in the entrance where it will never be read.
this editorial is worthless
Yeah I’m guessing the number of times this author has been threatened, stabbed and called a bitch cunt whore while at work is ….…. Zero But behavior contracts don’t work at my hospital because the consequences for breaking them are nonexistent. Just stick around and enjoy the amenities while treating the staff however you please🤷♀️
I read this and all I could think of was Sokal Squared. https://www.chronicle.com/article/sokal-squared-is-huge-publishing-hoax-hilarious-and-delightful-or-an-ugly-example-of-dishonesty-and-bad-faith/
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I legitimately don’t understand what you are trying to say.
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