Nephrology Ethics Forum

What is our duty to a “hateful” patient? Differing approaches to a disruptive dialysis patient

While the practice of medicine has changed over the years, including technological advances, access to medical information, and the narrowing of socio-economic and educational gaps between the clinician and his/her patients, the importance of the doctor–patient relationship has not diminished over time. This can be a very rewarding interaction. However, many physicians experience a great deal of anger, inadequacy and frustration, and much of the actual practice of medicine may become a burden rather than a source of satisfaction. Physicians may encounter a subset of patients who engender strong negative feelings, despair and even downright malice. An understanding of the “hateful patient” can therefore be very informative to the physician. Several categories of such patients may be described, and sensitivity to the phenomenon will lead to improved physician well-being, less self-destructive patient behavior and a lower risk of litigation. Several factors may assist the 21st century physician in managing the “hateful patient” in an empathic manner and in making some sense of why the patient has resorted to negative response patterns. Ultimately, a failure to consider these issues will result in poorer medical care and, no less important, reduced satisfaction of both patients and doctors. The intention of this article is to revisit the concept and to place it in the context of contemporary medical practice.

Se analiza la transferencia a una unidad de nefrología, la decisión terapéutica, el consentimiento informado, las recomendaciones sobre los tratamientos sustitutivos en la enfermedad renal crónica, la existencia de un documento de voluntades anticipadas, la discrepancia del consejo médico, el derecho a la negación de la terapia aplicada, el cese por el médico de la terapia elegida, el paciente como no-colaborador en el tratamiento, el protocolo de la lista de espera al trasplante renal, la oferta limitada de trasplante renal, las diferencias entre el trasplante renal y la diálisis y, por último, la información del trasplante de vivo y pediátrico

The clinical practice guidelines on ethics and nephrology, developed through consensus by the Spanish Society of Dialysis and Transplantation, analyze the following topics: referral to nephrology units, therapeutic decision-making,informed consent, recommendations on renal replacement therapy in chronic renal disease, the existence of an advance directive, disagreement with medical advice, the right to refuse the treatment administered, withdrawal by the physician of the treatment chosen, treatment in noncompliant patients, the protocol for entry to the kidney transplant waiting list, the limited supply of kidney transplants, differences between kidney transplantation and dialysis and, lastly, information on living donor and pediatric transplantation.

Based on casual conversations among those working in dialysis units, dialysis facility staff often face situations created by difficult or disruptive patients, yet relatively little is known about these situations. A computer interactive session at a national meeting in April 2000 was used to gather information on this topic from 203 persons who worked in dialysis facilities. Most respondents viewed situations with such patients as an increasing problem for the nephrology community. Although 71% of the respondents were frequently involved in the attempted resolution of these situations, only 50% indicated that they were adequately trained to intervene. Approximately 38% of the participants’ facilities had discharged a patient because of behavioral difficulties in the preceding year. Many facilities lacked policies that could provide guidance to both staff and patients about their rights and responsibilities, as well as policies that specifically addressed difficult/disruptive patient situations. These results highlight the need for increased training for personnel and the development of policies by dialysis units to address this increasingly common problem.