Cases That Test Your Skills

The nurse who worked the system

Current Psychiatry. 2009 July;8(7):69-76

References

1. Pasic J, Russo J, Roy-Byrne P. High utilizers of psychiatric emergency services. Psychiatr Serv. 2005;56(6):678-684.

2. Geller J, Fisher W, McDermeit M, et al. The effects of public managed care on patterns of intensive use of inpatient psychiatric services. Psychiatr Serv. 1998;49:327-332.

3. Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883-887.

4. Karlsson H, Lehtinen V, Joukamaa M. Are frequent attenders of primary health care distressed? Scan J Health Care. 1995;13:32-38.

5. Karlsson H, Lehtinen V, Joukamaa M. Psychiatric morbidity among frequent attenders in primary care. Gen Hosp Psychiatry. 1995;17:19-25.

6. Lefevre F, Refiler D, Lee P, et al. Screening for undetected mental disorders in high utilizers of primary care services. J Gen Int Med. 1999;14:425-431.

7. Pearson S, Katzelnick D, Simon G, et al. Depression among high utilizers of medical care. J Gen Intern Med. 1999;14:461-468.

8. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on medical adherence. Arch Intern Med. 2000;160:2101-2107.

9. Von Korff M, Ormel J, Katon W, et al. Disability and depression among high utilizers of health care. A longitudinal analysis. Arch Gen Psychiatry. 1992;49(2):91-100.

10. Watts D, Morgan G. Malignant alienation dangers for patients who are hard to like. Br J Psychiatry. 1994;164:11-15.

After a lengthy discussion among several psychiatrists, therapists, nurses, and attorneys, the treatment team decided to terminate outpatient care for Ms. Y at our facility because of her chronic nonadherence to treatment recommendations. Ms. Y had manipulated numerous providers in our department, called multiple doctors in our facility to ask them to care for her, and asked her ex-husband to contact the department administration on her behalf. Her behavior bordered on harassment. In addition, the interventions we provided were making her worse, not better. Factors that influenced our decision included:

Clinical Point

The team terminated outpatient care for Ms. Y in part because the interventions provided had made her worse, not better

fear of Ms. Y committing suicide
fear of setting limits
fear of being reported to the Medical Board
fear of a lawsuit.

The team sent Ms. Y a registered letter explaining the reasons for the termination and providing referrals for other providers in the area. She was told that she retains access to the ER and can receive inpatient psychiatric care, provided she first is evaluated in the ER.

Table 2

Strategies for helping 4 types of ‘hateful patients’

Dependent clinger
Behaviors	Shows extreme gratitude with flattery
Associated personality traits/disorders	Codependent
Management strategies	As early and as tactfully as possible, set firm limits on the patient’s expectations for an intense doctor-patient relationship. Tell the patient that you have limits not only on knowledge and skill but also on time and stamina
Entitled demander
Behaviors	Intimidates, devalues, induces guilt, may try to control with threats; terrified of abandonment
Associated personality traits/disorders	Narcissistic, borderline personality disorder
Management strategies	Try to rechannel your patient’s feelings of entitlement into a partnership that acknowledges his or her entitlement not to unrealistic demands but to good medical care. Help your patient stop directing anger at the healthcare team
Manipulative help-rejecter
Behaviors	Resists treatment; may seem happy with treatment failures
Associated personality traits/disorders	Psychopathy, paranoia, borderline personality disorder, negativistic, passive/aggressive
Management strategies	Diminish your patient’s notion that losing the symptom or illness implies losing the doctor by ‘sharing’ your patient’s pessimism. Tell your patient that treatment may not cure the illness. Schedule regular follow-up visits
Self-destructive denier
Behaviors	Denial helps them survive
Associated personality traits/disorders	Borderline personality disorder, histrionic, schizoid, schizotypal
Management strategies	Recognize that this type of patient can make clinicians wish the patient would die and that the chance of helping a self-destructive denier is minimal. Lower unrealistic expectations of delivering perfect care. Evaluate the patient for a treatable mental illness, such as depression, anxiety, etc.
Source: Reference 3

Table 3

Tips for managing high utilizers

Establish a collaborative treatment plan with firm limits and expectations Document the treatment plan and encourage the patient to actively contribute Provide the patient with a copy of the plan Have the patient sign release of information for other care providers and have active contact with them for continuity and accountability Specify that the patient can obtain prescriptions or have medication dosages changed only by a psychiatrist or primary care provider Document an emergency department treatment plan to prevent unnecessary medication changes, obtaining narcotics or benzodiazepines if the patient has chemical dependency issues, etc. Involve the patient’s family
Acknowledge your feelings and countertransference Have regular contact with a mentor or colleague for consultation Ask yourself: Are you working harder than the patient? Is the patient capable of working harder or complying? Keep in mind the difference between mental illness and bad behavior
Explore your patient’s expectations and commitment to treatment by asking: ‘What do you consider as barriers to compliance or improvement?’ (Share your thoughts with the patient) ‘What are you willing to commit to in order to get better?’ ‘If I had a magic wand that I could wave and fix1 thing in your life right now, what would it be?’ or ‘What is the number 1 area in your life that is causing distress?’
Practice safely and proactively Determine if the patient has an undiagnosed psychiatric disorder Provide a phone call reminder for appointments Call if the patient does not show up for an appointment Document, document, document

OUTCOME: The pattern continues

Ms. Y continues to receive treatment with a different outpatient psychiatrist and therapist in the area. She has not been hospitalized for almost 2 years but her financial state has deteriorated and she has had a recurrence of depression. Ms. Y’s psychiatrist recently called the hospital to ask for direct admission on the patient’s behalf, stating that Ms. Y did not want to wait hours to be seen in the ER. Hospital staff explained that she needs to first come to the ER for evaluation. Ms. Y refused to come to the ER and was not admitted. About 1 month later, Ms. Y’s psychiatrist called again, and she was directly admitted to the psychiatric hospital.

The nurse who worked the system

References

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