Nephrology care requires a long-term collaboration among the patient, his or her nephrologist, and the many other essential members of the healthcare team. However, in some situations, circumstances evolve to where it is in the best interest of all parties (including the patient) for a change in provider and/or facility. If an individual has a history of disruptive or maladaptive behaviors, the potential new provider or medical director is confronted with the dilemma of whether to accept the patient (1). There are a number of factors to weigh in making this decision (Table 1), running the gamut from ethical principles and obligations to practical concerns about quality metrics and reimbursement rates. The phrase “problem patient” is pejorative and is to be avoided. When one uses that phrase, often what he or she is referencing is troublesome physician-patient interactions or patient behaviors. The label, problem patient, however, can cause serious damage to an individual and prevent him or her from accessing necessary medical care.
If a patient has a documented history of disruptive or maladaptive behavior(s), it may be helpful to first take inventory of what is occurring with some degree of perspective and emotional detachment (2). Whether functioning as a clinical provider or a medical director, answering some key questions can be helpful in assessing whether to assume care for a patient with this type of history. Who, if anyone, do these behaviors put at risk? Could the behavior be a manifestation of a medical condition (Table 2)? Could these behaviors arise from problematic interactions where both the patient and others involved in his or her care (e.g., the provider, nurses, or dialysis unit staff) are playing a role, and could this dynamic be adjusted for a better outcome? Would the change in environment brought about by the patient joining your practice or dialysis facility potentially lead to the resolution of these issues? Unfortunately, it may not be possible to fully answer these types of questions with the information available at the time a decision needs to be made.
Dialysis facilities should have codes of contact that are shared with patients on admission to the unit and generally at specified intervals thereafter. However, it can be helpful to review these documents with a patient when troublesome behaviors occur. There are some patient behaviors, such as threats or violence toward other patients or healthcare workers, where rigid boundaries must be enforced. The diversity of legal statutes, institutional policies, and cultural practices makes it impossible to offer uniform guidance on how to proceed. Providers are encouraged to consult with their risk managers and other legal resources in specific instances.
In the vast majority of cases, it is in no one's interest, and is particularly unfortunate for the patient, if care devolves into frequent emergency department visits and emergent dialysis. Furthermore, even beyond ethical concerns, medical abandonment can put a provider in legal jeopardy when suitable alternative care has not been found. If the nephrology community has a collaborative approach, where providers and facilities in the area share an understanding that even challenging patients will ultimately need to receive care, then open and honest communication among the healthcare professionals can go a long way to building a foundation for successful transitions of care.
Jones ER, Goldman, RS. Managing disruptive behavior by patients and physicians: A responsibility of the dialysis facility medical director. Clin J Am Soc Nephrol 2015; 10:1470–1475. doi: 10.1159/000494592
Janosevic D, et al. Difficult patient behavior in dialysis facilities. Blood Purif 2019; 47:254–258. doi: 10.1159/000494592