Approaches to Negotiate With Disgruntled Patients, Families

Marcia Frellick

April 01, 2019

NATIONAL HARBOR, Maryland — Understanding why patients seek out medically inappropriate treatment or want to leave the hospital against medical advice is critical to providing better care for unhappy patients, experts said here at the Society of Hospital Medicine 2019 Annual Meeting.

One of the biggest mistakes physicians make is "having an agenda in mind and an outcome they are trying to achieve," said Nicole Adler, MD, from NYU Winthrop Hospital in Mineola, New York.

You have to understand "where the patient or family is coming from," she told Medscape Medical News.

Adler was one of three experts who spoke about having difficult conversations with patients about their care.

She described the case of a man in his 90s with end-stage dementia and metastatic lung cancer who was dying after weeks of aggressive second-line chemotherapy. Instead of a hospice discussion, the family was pushing for a third-line treatment option.

Dying Man's Family Pushes for More Chemo

In such a situation, the hospitalist should start by asking what the patient understands about his or her illness and what that means, Adler suggested. Then ask: "What is a good day for you?"

Specifically, determine how important it is to the patient to be able to live alone, to be able to feed him- or herself, and to be able to get out of bed. This information can help physicians explain why a treatment might not get patients to their goal, she explained.

Another case was presented by David Alfandre, MD, from the National Center for Ethics in Health Care at the US Department of Veterans Affairs.

He talked about a 40-year-old man with high blood pressure, diabetes, and alcohol use disorder who was admitted for acute kidney injury, but who wants to leave the hospital against medical advice.

"Physicians are not wardens," said Alfandre, and patients with decision-making capacity have the ethical and legal right to decline recommended inpatient care. However, physicians also have an ethical obligation to steer vulnerable patients toward the best health options, he added.

Letting the patient know he or she has the ultimate say on whether to stay or go might help diffuse the situation. In addition, family, friends, and perhaps an additional specialist can be enlisted to encourage the patient to stay in the hospital.

Understanding why the patient is making the decision to leave might open up some room for bargaining, said Carrie Herzke, MD, from Johns Hopkins University in Baltimore.

Perhaps the patient really just wants to be able to leave the floor to smoke, she said. If medically appropriate, a negotiation — offering the patient two 10-minute breaks to leave the floor — could keep that patient in the hospital.

With difficult patients, empathy almost always works better than argument, Herzke pointed out. An apology for things that have frustrated individuals but are beyond the control of the physician can also help.

The Blameless Apology

For example, the hospitalist can concede that the patient's frustration — that imaging was done in the middle of the night or that breakfast was late, or even that the patient had to be hospitalized in the first place — is understandable.

In such cases, a small effort — offering to see if vitals are necessary when the patient is asleep or if the meal plan can be changed — could bring about a change that satisfies the patient.

"This does not mean you sell your soul," said Herzke. "It's trying to think about things that are medically appropriate but can get you to partner with that family."

Adler, Alfandre, and Herzke have disclosed no relevant financial relationships.

Society of Hospital Medicine (HM) 2019 Annual Meeting. Presented March 27, 2019.

Follow Medscape on Twitter @Medscape and Marcia Frellick @mfrellick

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