Active listening key to dealing with difficult patients, families

The definition of a difficult situation different for every physician.

Issue: November 1, 2007

It is inevitable that physicians will face uncomfortable and/or difficult communications during the course of their practices. From dealing with patients’ families to transitioning patients to end-of-life care, physicians have many potentially daunting tasks in addition to monitoring medical treatments.

According to Walter Baile, MD, director of the Program in Interpersonal Communication and Relationship Enhancement at The University of Texas M.D. Anderson Cancer Center and Supportive Care section editor for Hem/Onc Today, dealing with patients who have unrealistic expectations, or who minimize the seriousness of their illness, is one of the most difficult situations physicians face.

“It’s inevitable that fellows or young faculty will run into one of these situations at some point in their training, especially at large academic centers,” Mark Klein, MD, instructor of medicine at the University of Minnesota and Fellows’ Affairs section editor for Hem/Onc Today, said in an interview. “It is important for fellows to pay close attention to how their mentors interact [with patients and family] in these types of situations.”

Difficult situations

The definition of a difficult patient or situation is different for every physician.

“There are some universal situations that seem to elicit strong feelings from everyone,” Baile said. “There are others that some clinicians are comfortable with but many others are not. In general, the most uncomfortable situations are ones that elicit strong feelings from the physicians, such as frustration, a sense of helplessness or even anger.”

At the root of most difficult situations are emotional issues that affect the patient but ultimately also the physician. “There are patients who have personality characteristics that lend themselves to denial. People with type A personalities may tend to experience their sickness as a severe threat and vulnerability and are more likely to mobilize denial and unrealistic expectations than others,” Baile said.

In many of these situations, the patients are coping with anxiety. One tool to overcome this is determining the source of the patient’s anxiety. In personalities where autonomy and control are over-valued, possible sources are the fear of depending on other people, losing control and the prospect of being disabled, according to Baile.

“It becomes a dual problem,” Baile said. The doctor’s own emotional response to the patient’s denial for example, may inhibit his ability to explore the patient’s concerns or underlying feelings. So before being able to respond effectively to the patient’s anxiety with an empathic statement to the patient such as “I know this is really difficult to cope with,” the doctor must put any emotional reactions he has on the back burner. “This requires some self-monitoring and avoiding reflexively reacting to one’s own emotions, which can be strongly aroused by certain patient situations,” Baile said.

In some situations, such as end-of-life and family interaction, Klein mentioned the use of ethics consults, where an objective third party will offer guidance.

“There are situations in which patients are no longer receiving benefit from aggressive therapy, but the patients and family want to continue the treatment regardless,” Klein said. “Sometimes hearing about the futility of further treatment from a third party can help the family.”

Family matters

Families are important sources of emotional support for patients and generally are an essential part of the treatment decisions, Baile said. For this reason, it is important to form an alliance with the families. They act as information conduits for the patients and also provide a way to help them with both emotional and practical support.

Klein said it is important to communicate with families on a regular basis and to be engaged with both the family and the patient.

“Spend extra time talking with the families and being present,” Klein said. “Physicians should gain a rapport with their patients’ families, which usually can only be done through positive interactions.”

Baile said that sometimes physicians can be overwhelmed by the number of family members who want to be involved in care. Physicians may also step into situations where they are in an unfavorable family dynamic, such as family members who are vying for control of the patient’s treatment. This type of dynamic often represents situations that have been around in the family for a long time, Baile said.

“It is a good idea to have the antenna up to recognize these types of issues when family interactions do not look or sound right,” Baile said. “It’s therefore important to check with the patient to determine what family members they do or do not want involved in their care.”

In some cases, family members who have not been involved with the patient for a long time arrive and immediately want to be involved in the negotiations regarding application of treatment. Both Baile and Klein stressed the importance of respecting the patient’s wishes and only providing information to the family members approved by the patient.

End of life

For patients with end-stage cancer, there usually comes a point where they would not benefit from more aggressive treatment. The adverse effects and complications from aggressive treatment would outweigh any potential benefit and would actually decrease the patient’s quality of life. In some cases, the patient and/or the family wants to continue with the treatment regardless.

“Getting around this situation is quite difficult,” Klein said. “It is best to discuss the situation with the family and patient and help them understand that the treatment is futile.”

The switch from aggressive treatment to palliative care is a fine line for all physicians. According to Klein, some physicians may continue with the aggressive treatment at the family’s or patient’s request. Although that may be easier, it may be harmful to the patient. In this situation, sometimes a second opinion from another physician may help the patient and family understand and accept the situation and the futility of further treatment.

According to Baile, this situation is common when the patient is a child, and family members are dealing with their fear of loss and pushing hard for continued therapy. When parents are feeling desperate in the face of no further viable anticancer treatments, they need to be approached with a great deal of sensitivity and understanding, but also be reminded that ineffective treatment can also prolong a child’s suffering.

Baile suggested that physicians begin by making sure the family members know the medical facts, since they may have the impression that prospects for a favorable outcome are more hopeful and may not understand the adverse effects associated with continued treatment. Giving bad news is almost always accompanied by strong emotions and these should be acknowledged.

Physicians should also not be afraid of acknowledging their own frustrations and disappointments in situations that therapy has not worked. “Emotional detachment in decision-making does not mean that doctors can never express their own feelings or frustrations to the patient or family,” Baile said. “It’s important that if a patient’s course does not go for the better, it can actually be helpful in aligning with the family to express your own feelings as it relates to the situation. When doctors don’t talk about their feelings, they tend to build up and not go away.”

Some physicians in fact begin to avoid seeing patients who are facing the end of life because of their own feelings. One strategy for connecting to the family in this situation is to express appreciation for the family and admiration for a patient for sticking with therapy and being courageous. An important pitfall to avoid is arguing with the family on ethical grounds or seeking to assert your own authority.

Baile also said that it is important for physicians to be aware of their own feelings when facing this situation with their patients. “It is important for fellows to pay close attention to how their mentors interact [with patients and family] in these types of situations," Klein said. – by Emily Shafer