When working with patients or loved ones who are confrontational, recognize your own feelings, try to understand theirs, and know when to ask for help from colleagues.
“What are the kidney numbers?!”
This question, or something similar was hurled at me by my patient’s daughter each morning, immediately upon entering the room. Her mother was hospitalized with severe, right-sided heart enlargement and failure. With her chronic kidney disease, fluid balance was virtually impossible. There was no way to adequately improve her symptoms without worsening her kidneys. She had either declined or was not a candidate for dialysis, and so we were left with a situation without much hope for improvement.
Our patient was kind and likeable; her daughter was not. She was angry, judgmental, and accusatory when the numbers got worse, when we didn’t know lab values immediately, when her mom’s symptoms worsened or changed. I always felt on the defensive. I thought I recognized some aspects of this behavior that hid the feelings that lay beneath: her fear, sense of impotence, and loss. I suspected that her daughter’s compulsion to attack us daily over the labs, oxygenation, constipation, and/or arthritis pain, was from a desire to feel some level of control, and a need to direct her anger, to blame someone. Who knew if she felt guilty, angry at her mother or herself, us, and/or the situation. It didn’t really matter. She directed it all at us, her medical team.
I’d had patients like this before and usually didn’t take it too personally because I thought I understood its underpinnings and was sympathetic. Like all of us, I try my best to do right for my patients and their families and feel bad and sometimes guilty when I can’t. I have different ways I try to connect, to bridge the gaps in knowledge and medical lingo, socioeconomic or educational status, personalities, and/or distrust and other feelings. Usually, I’m able to offer support and possibly some solace by being understanding and giving my time.
But I just couldn’t connect with this daughter. Despite doing all the things I usually do, she remained just as angry, demanding, provocative, and unpleasant. So, I started avoiding her. I waited to see my patient until after her daughter had left. I sometimes skipped checking in on my patient, passing by the room to eyeball her from the outside while relying on my residents’ summary to guide her care. I felt guilty even though I knew there wasn’t much we could do for her, because I was avoiding my clinical responsibilities due to my own discomfort. I knew she was getting the appropriate medical care, but my own contribution was lacking and my physical presence in the room some days was absent.
What does one do when one can’t connect with a patient or family member? When, despite patience and understanding and lots of time spent trying to communicate and sympathize, there remains a barrier that can’t be traversed, with anger and judgement being the sole means of communication? I don’t know if there’s a right answer, but I feel that some things may help.
1. Recognize and understand your own feelings, especially feelings of discomfort. For example, ask yourself, “Why am I feeling so defensive?”
2. Recognize and understand your patients’ feelings in order to see their point of view.
3. Find a way to give excellent care despite any underlying emotions. See if there’s a bridge to caregiving that minimizes conflict and discord.
Finally, if differences can’t be broached, see if there’s another clinician whose personality and approach may be more compatible with the patient.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.