It’s extremely hard being in a room with a family that is angry, confrontational, and hostile,” says clinical social worker Jane B. Hawgood, MSW, who often works with the hospitalist group on the General Medicine Service at the University of California at San Francisco Medical Center. “When you read about these cases in a textbook, it seems so clean and neat.”
Hospitalists have all encountered them: family members who, because of their behavior toward providers, come to be labeled as “difficult.” What are the best ways to deal with patients’ family members who are unresponsive, overbearing, or outright hostile to physicians and the care team? And how do you proceed to a treatment plan that is best for the patient?
The first step, believes Thomas Baudendistel, MD, FACP, associate program director of the Internal Medicine Residency Program at Sutter Health’s California Pacific Medical Center in San Francisco, and chair of SHM’s Ethics Committee, is to avoid using the term “difficult.”
“I think ‘difficult’ is a loaded term and kind of pejorative,” says Dr. Baudendistel. “When their loved ones are in the hospital, families are vulnerable. They don’t really know what to expect. I don’t know that I wouldn’t want my grandmother, or mother described as a ‘difficult patient,’ or a family member described as ‘difficult.’ Rather than saying, ‘this is a difficult family member,’ I would rather phrase it, ‘This is someone who has a lot of worries.’ ”
Hawgood employs a similar approach. “I like to define the situation as ‘a family member who is having difficulty dealing with the patient’s illness,’” she says. “If I hear, during rounds, that this family is difficult, I immediately begin asking myself, ‘Why are they having difficulty? Is this an interpersonal issue? Does this family member have a psychiatric history? Is there a history of a past problem with the medical system? Is it a financial issue?’ I really try not to presume things. I always try and keep an open mind about what a patient’s and family’s goals are, and what I can do to help. You need to clearly understand your goals and have good support from your team to redirect the energy.”
“Unrealistic expectations” might describe some of the encounters for Adrienne Bennett, MD, director for the Division of Hospital Medicine and associate clinical professor of medicine at Ohio State University. In her former post as founder and director of hospitalist services at Newton Wellesley, a community teaching hospital in the western suburbs of Boston, she and colleagues dealt with a relatively affluent patient population. Some of the patients and families, she says, “can sometimes be somewhat demanding and difficult if they feel they aren’t getting what they’re entitled to. In that sense, they can become ‘the angry daughter,’ as my colleague used to say.”
—Jane Hawgood, MSW
Because they do not have an ongoing history with patients, hospitalists may often be starting at a disadvantage in forming a new relationship. Dr. Baudendistel believes hospitalists can quickly learn the skill of reassuring patients and their families. One way to do that, he says, is to “link with the primary care physician.” He often calls the primary care physician and tells the family of his conversations with the family doctor, thus establishing a level of comfort for them. He makes it clear to the family that he is available to them, giving them phone and pager numbers so they can easily reach him.