Appears angry, fearful, somewhat disheveled. Cursing at police and ER staff.

13 Pages·2009·1.04 MB·English

by  Carolyn Crown

Stephen M. Goldfinger, MD
Chart Review: The Patient You Hate to Treat
PATIENT INFO

31 / Male
Age / Sex: ________________________________________________________________________________________
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Presenting Complaint: Appears angry, fearful, somewhat disheveled.
Cursing at police and ER staff.
* bid = twice daily; hs = at bedtime.
BEST PRACTICES
List three best practices agreed to by the group in your chart review session:
1. Clinicians want to love all, cure all, know all. They can(cid:146)t.
2. The most dangerous (cid:147)hate(cid:148) is one that is unconscious. Allow yourself to acknowledge you may (cid:147)hate(cid:148) a
patient; just don(cid:146)t act on it.
3. Patients usually don(cid:146)t follow directions. Begin with relationship development (therapeutic alliance),
maximizing patient independence and autonomy to maximize likely adherence.

The Patient You
Hate to Treat
Chart Review
Stephen M. Goldfinger, MD
SUNY Downstate Medical
Center
Stephen M. Goldfinger, MD
Disclosures
Research/Grants: Avantis Medical Systems, Inc.;

Danippon Sumitomo Pharma; H. Lundbeck A/S;
Janssen, LP; Pfizer Inc.; Roche Labs
Speakers Bureau: Teva Pharmaceutical

Industries Ltd.
Consultant: Teva Pharmaceutical Industries Ltd.

Stockholder: None

Other Financial Interest: None

Advisory Board: None

Learning
Objective
Describe strategies to
better engage “difficult”
patients in a
constructive
therapeutic relationship
in the inpatient setting
Case: Mr. Jones
31-year-old bi-racial male admitted to

hospital through Psychiatric Emergency
Services
– Brought to ER by police after he smashed
furniture in the homeless shelter where he lives
Third hospital admission in the last 6

months, and his 14th in our hospital
Appears angry, fearful, somewhat

disheveled
– Cursing at police and ER staff
Case: Mr. Jones (cont.)
Was discharged from hospital 3 weeks ago after

3-week stay
– Somewhat uncooperative at discharge, but denied
violent urges, suicidal thoughts, and hallucinations
– Had been stabilized on olanzapine 15mg/day,
divalproex sodium 500mg bid, quetiapine 100mg hs
– Accepted prescriptions and referral to 12-step program
to address drug use he disclosed in group therapy
– Refused any residential program but accepted shelter
referral
– Shelter reluctantly accepted him despite previous
assault on another resident
bid = twice daily; hs = at bedtime
What 3 Questions Do You Most
Want Mr. Jones to Answer?
MY list would include:
Have you ever found anyone in the mental

health or residential system helpful? WHY?
Have you ever taken ANY medication that

you’d want to continue taking? Did you?
Why did you stop?
If YOU were me, how would you help the guy

sitting in front of you? What would be hardest
in getting him what he wants?
Management Strategies for “Difficult”
Patients in the Inpatient Setting
Scant data on management strategies in “difficult”

patients
General recommendations based on literature:

– Maintain a validating attitude
– Create strict boundaries within a clear treatment
structure
– Remain conscious of patient’s background and one’s
own limitations
– Consultation and supervision may provide new
perspectives
Koekkoek B. Psychiatr Serv 2006;57:795-802.
Discussion Questions
What would you do with Mr. Jones while on

inpatient service?
What would you expect the primary issues to be?

Would you accept him as an outpatient?

Would you want him as an outpatient?

What community resources would you need to

work with?
How many of those resources exist in your

community? Who can access them?