Dealing with aggressive patients

Over a third of doctors have experienced verbal or physical abuse from patients or patients’ relatives during Covid-19, including outside of a medical setting, according to a recent survey. Medical Protection medicolegal consultants, Dr Rachel Birch and Dr Clare Devlin, offer advice on handling aggressive patients

More than a third of doctors have experienced verbal or physical abuse from patients or patients’ relatives during Covid-19, according to Medical Protection’s recent survey of 361 doctors in Ireland.1

A further 7 per cent of doctors reported receiving verbal or physical abuse outside of a medical setting, according to the results published last November.

Some patients have a history of aggressive behaviour, so general practitioners (GPs) may anticipate recurrence, particularly in times of widespread stress and uncertainty such as the current pandemic. For other patients, aggressive behaviour is uncharacteristic, but may present as a feature of an underlying physical or mental condition.

It is helpful to have a practice policy to deal with aggressive behaviour and ensure that staff receive training in conflict avoidance. This may enable signs of aggression to be recognised at an early stage, such as body language signalling increasing frustration or anger, thus avoiding escalation.

Patients can be made aware of the practice policy through a notice in the waiting room or on the practice website.

Dr Rachel Birch. Photo: Cate Gillon

When faced with an aggressive patient
Doctors may be able to defuse the situation by remaining calm and clearly demonstrating a willingness to help the patient. They should avoid raising their voice or adopting confrontational body language, such as crossed arms or entering the patient’s space. Allowing the patient to talk and listening to them often helps, as does acknowledging their feelings and perspective — understanding their point of view does not mean agreeing with it. Asking open questions may help calm the situation, or it might be better to allow the patient to speak uninterrupted.

The GP may identify if the patient has any legitimate concerns, and if appropriate, apologise and offer to discuss and address any complaints, although a productive discussion is likely to take place at a later point when emotions are less heightened.

Medical practitioners also need to be mindful of their own safety, considering whether they are in a position to leave the room if necessary. In a situation of violence or anticipated violence, call the Gardaí, rather than attempting to physically escort the patient from the premises.

After the incident
It can be distressing to deal with an aggressive patient, so debriefing with supportive colleagues can be valuable and generate useful learning points about ways to manage a similar situation in the future.

Consideration should be made whether to document the patient’s aggressive behaviour on a case-by-case basis. If you believe it is likely to be relevant to their health, it should be documented in their medical record.

Dr Clare Devlin. Photo: Tim Hardy

The Medical Council2 advises that information recorded in the patient’s notes must be accurate and up-to-date, consisting of the relevant information learned from or about patients. Their guidance emphasises that there should be no discrimination against patients on any grounds. So, it would be prudent not to include personal opinions, and instead of stating a patient was aggressive, it would be preferable to give a factual description of the words they used, their tone of voice, gestures and posture.

It is important to remember that information held by the practice about a patient, whether in the medical records or elsewhere, would need to be disclosed at their request under General Data Protection Regulation (GDPR).

Warning a patient about their behaviour
A doctor may wish to consider giving a patient a warning about their behaviour. However, warnings may be the trigger for a complaint, so it is important to take care with the wording of any warning letter. They should set out in neutral terms the behaviour they do not wish to be repeated, and the consequences, for example, that repeated incidents of a similar nature could result in consideration of the patient’s future with the practice. It can also be effective to start with an apology for any issues that had upset the patient, for example, delays or communication problems.

The medical practitioner can explain they understand the patient may have been distressed or anxious, before then outlining that this is still not an excuse for unacceptable behaviour. It is helpful not to make direct accusations, but rather refer to any aggression or intimidation in terms of it being the perception of the staff concerned.

The doctor could add that they realise the patient might have been unaware of the effect of their behaviour and give them an opportunity to provide comments. This can often lead to an apology from the patient which enables swift resolution.

Removal from the practice GMS list
Removing patients is an emotive issue that can open the potential for criticisms of poor care. Sometimes, though, the doctor-patient relationship breaks down to such an extent that it is in the patients’ best interests for them to be treated elsewhere.

The Medical Council2 advises that, if unable to continue to care for a patient, a doctor should advise them of this, being mindful that they still have an ethical duty to continue to care for the patient until alternative arrangements for their care are put in place. Remember, doctors remain under a duty to always provide care in emergency situations. They should facilitate transfer of medical records, with the patient’s consent, to their new GP.

If the GP wishes to discontinue treating a public patient, doctors should advise the Health Service Executive (HSE) of this fact and the reasons why. It is a good idea to notify the patient in writing that the HSE will make alternative arrangements for their care, as a matter of courtesy and good practice, and to avoid the patient making a complaint relating to poor communication. The doctor should transfer any medical records promptly and provide care as appropriate in emergency circumstances.

References

  1. ‘Third of doctors suffer abuse during pandemic’, https://www.imt.ie/uncategorised/third-doctors-suffer-abuse-pandemic-06-11-2020/.
  2. https://www.medicalcouncil.ie/news-and-publications/reports/guide-to-professional-conduct-ethics-8th-edition.html.

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