Download Difficult clinical encounters

Challenging
Behaviours
Challenging Behaviours
Patients Seeking Medications:
Your Experiences
Describe a situation where a patient requested
medications you believed were not justified from a clinical
perspective (i.e., you thought they were ‘drug-seeking’).
• Describe the scenario
• How did you feel?
• How did you respond?
• How did the patient respond?
• What was the outcome?
• What would you do next time?
• What protocols are there to assist you and other
staff to respond to future situations?
Challenging Behaviours
Managing Challenging Situations
• Every general practice should have relevant
protocols in place to meet clinical, ethical and legal
requirements and patient demands
• There are inherent difficulties for GPs associated
with:
• patients who appear determined to obtain drugs
through inappropriate means or behaviours (or
‘doctor shoppers’, in the absence of better
expression)
• patients or others who are intoxicated
• patient behaviours that are incongruent with the
agreed treatment plan.
Challenging Behaviours
Principles of Management
• Safety (patient, self, staff, other patients)
• Prevent temptation (hide prescription pads / sample
medications, anything of value, etc.)
• Advise patient of obligations & limitations of
prescribing regulations in your jurisdiction
• Offer alternatives rather than refuse treatment (p.r.n.)
• If necessary, contact the police and/or jurisdictional
Health Department
• Restrict harm by limiting number and dose of
medications prescribed.
Challenging Behaviours
Patients Seeking Medications (1)
• May give you a seemingly ‘well-rehearsed’
scenario describing e.g., insomnia, stress,
alcohol withdrawal
• May be familiar with drug names
(though may mispronounce them)
• May request specific drugs and quantities
(and be aware of specific drug actions)
• May express reservations about alternatives
(esp. non-drug alternatives)
• May seek analgesics for ‘difficult to assess’ pain.
Challenging Behaviours
Patients Seeking Medications (2)
• May be increasingly anxious or agitated if
sensing your reluctance to prescribe
• May have other significant drug use patterns
or related problems (e.g., already prescribed
therapeutic dose)
• May punish or reward the GP according to
response
• May complain of opioid (or other) allergy or
side effects to suggested medications (esp. if
seeking Pethidine by injection).
Challenging Behaviours
Responses to ‘Drug-Seeking’
Behaviour (1)
• Ensure safety
• Offer comprehensive assessment (for pain or other
ailment) incl. physical examination, AOD history/existing
dependence
• Don’t prescribe on first visit
• Say ‘no’ to scripts but offer appropriate medical advice
• Offer information regarding harm minimisation strategies
• Offer assistance (when required) or referral for drugrelated issues.
Challenging Behaviours
Responses to ‘Drug-Seeking’
Behaviour (2)
If the GP decides to prescribe:
• restrict harm potential by limiting number and dose of
medications prescribed
• prescribe NSAIDs or other non-opioids
• if BZDs indicated, prescribe long acting forms, time
limited, in small quantities
• decrease prescribing or dispensing periods
• negotiate alternative stress / anxiety or insomnia
treatments while drug use is being phased out
• monitor for transfer of dependence to other drugs.
Challenging Behaviours
What concerns may GPs have regarding
‘drug-seeking’ behaviour in the
General Practice setting?
How can GPs plan for future situations,
and ensure an appropriate and
consistent response?
Challenging Behaviours
Intoxicated Behaviours Include:
• Poor memory and retention
• Poor attention, concentration or gaps in
understanding
• Slurred speech
• Disinhibition and mood swings (unpredictable)
• Inappropriate or poor reactions to verbal
instruction or commands
• Poor judgment, confusion, frustration.
Challenging Behaviours
Misdiagnosis
Intoxicated behaviours may mimic a range of other
conditions such as:
• concussion (confusion, disorientation)
• CVA / tumour
• hypoxia
• dehydration
• shock
• diabetes
• septicaemia
• UTI
• post-ictal confusion.
Challenging Behaviours
Responding to Intoxication (1)
Assess and Examine
•
AOD history (e.g., pattern, quantity and recency of last use)
•
physical exam (for other possible conditions)
•
avoid a prolonged consultation
•
do not make final decisions on treatment options (they may
not remember)
•
ask about suicidal ideation / plans (referral may be required)
•
explore options for sobering up and/or drug withdrawal.
Observe
•
is presentation consistent with reported use? (exclude any
physical complications)
•
if intoxication does not resolve within expected time frame,
something else is happening!
Challenging Behaviours
Responding to Intoxication (2)
Respond
•
avoid psychoactive medication
•
avoid anything requiring consent, if possible
•
consider ethical and legal consequences of sending an
intoxicated person away (e.g., if driving)
•
if appropriate, refer home or to a designated place for observation
•
use harm minimisation approaches.
Arrange
•
a safe means of getting ‘home’ or to a place for observation
•
for review/follow-up.
Challenging Behaviours
Communicating the Role of the GP
to the Patient
•
AOD issues are health problems, not moral or ethical issues
•
A clear and non-judgmental approach assists in building and
developing rapport with all patients
•
A quality assessment includes ensuring an understanding of the
patient’s issues, and the patient’s perspective on life
•
Whatever a patient’s circumstances, a recent history should be
part of routine clinical assessment
•
Communicate clearly your role, what you need to know to help
your patient, and why you are asking about AOD issues
•
Set limits – be clear about what you can and can’t do
•
Listen to the patient’s concerns, and his or her requests without
prejudice.
Challenging Behaviours
Effective Communication when
Patients are Feeling Defensive
• Remain calm
• If the patient becomes angry or aggressive:
• demonstrate calm control, avoid becoming emotional
• keep your voice low
• sit, or stand, side-on to the patient
• use the patient’s name
• acknowledge the patient’s feelings, and encourage
the patient to take control of his or her emotions
• Safety – scan the room in case you need a quick exit.
Challenging Behaviours
The Patient’s Perspective
What would be your response if the patient said...
• ‘GPs are patronising or antagonistic, so they
earn their dislike, distrust, or anger’
• ‘GPs can make you feel humiliated and
manipulated’
• ‘GPs make you comply with unrealistic
treatment regimes’
• ‘GPs don’t understand what it is that I need, so
I have to behave in a way to ensure my needs
are met’
• ‘GPs don’t understand that ‘it’ is needed now!’
Challenging Behaviours
A Balancing Act
• All patients, regardless of their behaviours,
have legitimate needs that should be
addressed
• Offer some negotiated treatment within a harm
minimisation framework so their needs are at
least partially met
• Do not meet patient requests when to do so is
potentially harmful
• Share the care with AOD specialist agencies
whenever possible.
Challenging Behaviours