Difficult patients present us with their own communication challenges. It can be easy to get caught up in the swirl of complaints. Do you avoid those situations or address them directly?

CASE

I arrived at Sam’s hospital room in time to hear him say to his nurse, “I’m tired of people getting in my business. I told you I need something for pain. What part of that don’t you understand?”

His nurse, Kirsten, rolled her eyes when she came out of the room. I followed her to the nurse’s station. “Sounds like he is having pain.” I said.         

“It’s always something with him. I’ve taken care of him for 2 days in a row and I’m glad I’m off tomorrow.” She rolled her eyes again.

What I said was, “He’s a handful.”

“That’s one way of describing him.”

Another nurse chimed in, “He is driving all of us nuts.”

When Kirsten hurried past me her body language communicated more than her words.

What I didn’t say was, “Give him a break, he’s dying of cancer.”

What I didn’t say was, “Sam takes a little getting used to.” 

What I didn’t say was, “I don’t think you should talk about him that way.”

Sam was admitted to the ICU with abdominal pain, anasarca, and shortness of breath. By the time he was transferred to the DOU he had outworn his welcome. On his transfer out of the ICU one of his nurses said, “Wow, glad to see him go.” Everywhere he went he alienated the staff.

I had known Sam for more than a year, yet whenever I saw him I was never sure which Sam I would meet; the sweet intent one who looked at me with dark brown eyes that creased at the edges when he said, “How you doing today?” or the Sam I saw more often, the angry, almost paranoid person who looked at me with the same dark brown eyes suddenly deep as a black cave, surprising me with his quick shift in temperament as he abraded me by saying, “What do you know, anyway?”

I had gotten used to expecting his mood swings though I was never certain what set them off. We came to terms. A little humor went a long way. When he targeted me, I wagged my finger at him and said, “Oh, no. Let’s stay on track Sam.” I had to remind myself that his fluctuating temperament was not his fault, that his lack of education did not mean he was stupid. He was entrenched in certain behaviors and didn’t want to change. He’d had surgery and chemo, and had lived with pain for a long time. I reviewed the care plan with him several times. He was supposed to call before he came to the cancer center to pick up a prescription, but instead he would just show up. The secretary would call me and hand the phone to him, and I said the same thing each time, “You’ll have to wait. I’ll be there as soon as I can.” And he said the same thing each time, “Okay.”

He didn’t call ahead of time because he wasn’t sure how he would feel in the morning. To get to the center he had to take two buses and walk several blocks, never certain how long it would take him. We became his port, and he was tethered to us by his need for pain medication. His metastatic colon cancer caused severe abdominal pain that was never completely controlled. Sam had his own ideas about how to take pain medication, refusing a long acting pain medication and instead relying on immediate release pain meds.

Somehow that made more sense to him. His previous addiction to illicit drugs fueled his resistance to taking a long acting, which he linked to addiction. Regardless of my efforts at educating him about long acting versus short acting, addiction versus dependence, he told me, “I know more about addiction than you do,” which was true. I abandoned any idea of getting him to change his pain medication regimen; instead, I was the one to adjust.

We could do a better job controlling his pain, and for a while I tried to insist he follow our recommendations. “This is a better way. We can get you more comfortable.” But to no avail. Finally, we settled on a pain management plan he was willing to adhere to. To assuage my need to direct his regimen, I told him, “Ok, we’ll do it your way; but if it doesn’t work, maybe we can try my way.” He always smiled when I said that.

DISCUSSION

How could I expect the floor nurse to understand Sam after 2 days when I was still trying to figure him out after a year? He was difficult, yet his volatile personality hovered over a core I could only describe as sweet, a soft filling he hid well, especially in new situations. It took me a year to understand how afraid he was and that he had probably lived his whole life in fear.

What I didn’t say to the nurse I didn’t say because I was uncertain of how to say it. My hesitation came from my anxiety. If I commented in a way that sounded like a scolding, I would alienate his nurses. If I said something defensive, his nurses might feel justified in their negative attitude. Yet agreeing with those negative comments was more than unprofessional, it was a kind of betrayal of Sam. Even in so-called ‘ideal’ circumstances, effective communication is a challenge. And difficult conversations are by nature difficult.

In an interesting irony as I was mulling over how else I might have managed the situation, I observed a colleague handle a potentially problematic situation. A doctor, one known to be difficult, was loudly expressing her dissatisfaction with a patient discharge. Rather than explain what happened or getting defensive, my colleague said to the physician, “Tell me more about your concerns.” It was simple and neutral. And it worked. When the nurses complained about Sam (and it wasn’t just nurses who complained about him), I might have said the same thing. Next time I face a difficult conversation, I will try a similar approach.

As for Sam, he died on his own terms, at home without hospice or home health, as independent as ever. Cranky, I’m sure. Scared. Probably with pain we might have managed if he had let us but he didn’t. What I didn’t say bothers me but it directs my interactions with other patients. Cranky, obstinate Sam, and the sometimes sweet, humorous Sam is part of my practice and a reminder that I can do a better job communicating.


Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.