The Uncooperative Patient- The Radiology Resident’s View
As a radiology resident, the patient experience differs greatly from other specialty services. Typically, he or she sees a patient for a solitary encounter or even less commonly, a second or third chance episode. Rarely, does the radiology resident have continual exposure to the same patient. He/she has limited time to interact with the patients, even more so than other clinicians. Therefore, the radiology resident does not often establish deep connections with our patients that other specialties may have. So, we have to view our experience through a very different lens.
In our “radiology world”, all of us will be involved in one of these dilemmas: The patient may refuse to drink barium, deny the imaging department the crucial second portion of a test, physically combat the staff, refuse procedure consent, move during a study, or be noncompliant with our instructions. In these situations, we often do not have the full picture of why the patient may not be cooperating. So in this discussion, I will go through how you, as radiology residents, establish a rapport with these patients to motivate the patient to complete a test. Also, I will discuss a couple of typical situations with “uncooperative” patients that you may encounter and how you can prevent them from escalating from bad to worse.
Patient Rapport and Motivation
As a human being, I can think of nothing less motivating than doing something for someone that I don’t know and for a reason that I don’t understand. Many times, this is exactly the situation that the patient is experiencing. The patient is often brought down to our department without a clue as to what test they are having with people they don’t know. They may be placed in confined quarters with minimal, if any human interaction.
Think about it… Imagine coming down from one of the floors to have a procedure such as barium enema and seeing someone without any identification whatsoever. As a patient, I can picture the thoughts going through his/her head. Is this person qualified to do the procedure. Am I going to be butchered by someone I don’t even know? Patients in this situation can often feel dehumanized and vulnerable. How can we minimize this poor patient experience? The first step is very simple: introduce ourselves. Who are we and why are we there? This alone, can motivate a patient to complete a study.
Secondly, explain the procedure. I have found that taking the time out to simply explain a procedure will often times go a long way to diffusing a potentially intense situation. Not only does explaining the procedure make the patient more comfortable and knowledgeable about his/her own care, but it also establishes that you are a professional that will be competent to perform a procedure.
And finally, let the patient know if you are going to be the one that is performing the procedure and, if not, at least you will be around to monitor him/her when the procedure is occurring. What a relief to know that there is someone in the department that has your back!
A Couple of Special Situations
The Combative Patient/Family
So, you are on interventional radiology for the month and are on your fourth consent for the evening prior to finishing up with your work. In the back of your mind, you are thinking that you are soon finally going home. You enter the room and introduce yourself to the patient and daughter. Subsequently, you start to discuss a PICC line consent that you have planned for tomorrow’s morning procedures and you begin to rattle off the risks, alternatives, and benefits to the procedure. As the discussion ensues, you notice on the door of the room a sign saying feeding precautions: Severe Risk of Aspiration- Do Not Feed the Patient! You then look back to the patient/daughter and notice that the daughter is rapidly shoveling food from home into the patient’s mouth. You halt the discussion and say to the daughter, “You really shouldn’t be feeding your Mom. She has aspiration precautions and can choke on the food that you are giving her…” The daughter yells back, “How Dare YOU Tell Me How to Treat My Mom. She Has Not Eaten For Days And I Will Give Her What She Wants!!!!” The patient then begins to cry and the daughter gets right up into your face in a threatening way as if she is going to punch you in the face.
How would you deal with a real world possible situation such as this? There are several options. But, as a radiology resident with limited knowledge of the patient’s situation, you need to treat it a bit differently than a primary care doctor or a specialist that sees the patient every day.
As a radiology resident, of course you first need to make sure to deescalate the situation. You do not continue to argue with the patient’s daughter as it could lead to physical confrontation or worse. In addition, there may be more to this situation that meets the eye. Perhaps, the daughter is responsible for the patient’s care and has an advance directive to feed the patient that may not be specified on the sign in the front of the room. You just don’t know.
Second, you may want to reflect and say something like, “Sorry… I see you are upset. Why don’t I leave the room and get you someone that may know more about the situation and can help you out.” You can then temporarily step out of the room and recruit the help of the caring physician or the nurse around the corner.
Your role as a radiology resident is not the total care of the patient. It is to be the physician that ensures the patient can go for a procedure the next morning. Therefore, it is appropriate to let the caring physicians and nurses know what is happening so that if there is a potential life threatening emergency for the patient, it can be taken care of expeditiously. Do not argue with the patient as it can lead to a more active confrontation!
The Obtunded Patient
On interventional radiology rotations, this is a frequently encountered dilemma. You go upstairs to the floors and you begin to consent a patient and you realize as you are going through the motions that the patient doesn’t understand a word that you are saying. What do you do???
First thing, check the charts. See if there is anything in the chart that confirms that the patient is not competent to make a decision. If not, what do you do? Make sure to think about whether or not the procedure/test is truly indicated emergently. The consent can certainly wait if it is not emergent. On the other hand, if the procedure is truly necessary, step out and ask the primary covering physician- what is the patient’s situation? Has there been a recent change in mental status? Is the patient on medications that are preventing him/her from understanding/responding to the consent? If there is a temporary change in mental status, maybe there is a better time/place to consent the patient.
If the procedure is emergent and really needs to be completed first thing in the morning, then what is the next step? It is your responsibility to find the person responsible for the patient’s care when he/she is obtunded so that the patient can be consented. You may find an advanced directive in the chart that gives clear instructions as to who is responsible for this patient’s care. Or perhaps, the nurse or physician may know who to contact in this event. In either case, make sure to contact the patient’s responsible decision makers prior to getting consent. If you do a procedure and it has not been consented by patient with mental faculties at the time, the consequences can be dire including the potential for legal action. Never allow an obtunded patient to sign off on a procedure!!!
Lessons To Be Learned About The Uncooperative Patient
The uncooperative patient is usually “uncooperative” for good reason. As radiology residents, we are often not privy to all the information that may lead to the patient’s attitude or actions prior to or during a diagnostic or therapeutic radiology procedure. Also, remember that you are not alone in making decisions for the patient. Always get help from other clinicians when needed. And, never make assumptions about the patient without getting the facts straight. Not following these guidelines can lead to patient care disasters!!!