Rebecca Fromme, Ph.D.McGuire VAMCGeriatrics and Extended Care

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

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

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

Challenging behaviors continued Medical providers and staff became more

concerned, frustrated, worried, guilty Staff decided to regroup, try something

else…..

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

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

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.

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”

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?”

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?”

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.”

Fewer aggressive episodes Slightly improved compliance with

dialysis through compromise Reduced verbal abuse Reduced staff stress Improved patient satisfaction