Editor- Intuitively, it must be true that the relationship between the doctor in the dialysis unit - the nephrologist -- and the patient are key to optimizing outcomes in the dialysis unit. This relationship must be founded on the trust and confidence that the patient has in his or her treating physician. J. Clint Parker explores this issue through the lens of "the difficult patient-physician relationship".
Dr. J. Clint Parker is a private practice nephrologist in Greenville, North Carolina. He is also a co-instructor in the M-1 Medical Ethics class at the Brody School of Medicine and Chairman of the Medical Ethics Committee at Pitt County Memorial Hospital. Dr. Parker contributed an earlier commentary on "Cherry Picking in ESRD patients: Should We be Concerned?"
COMMENTARY - Dr. J. Clint Parker
In the patient-physician relationship both parties work together in a context of shared decision making to reach mutually agreed upon goals that lead to excellent outcomes for the patient and a sense of professional satisfaction for the physician—but sometimes it doesn’t turn out this way. As Hashmi et al. note in a 2008 review published in Nature Clinical Practice: Nephrology the problem of disruptive or difficult dialysis patients is becoming increasingly more common and can manifest in a variety of behaviors (1). They categorize these behaviors according to the primary recipient of harm. Some behaviors such as non-adherence to diet, medications, or dialysis prescription are primarily harmful to the individual patient; some behaviors such as late arrivals or filing unsubstantiated claims with ESRD networks or health departments are harmful to the efficient operation of the dialysis unit; and some behaviors such as verbal abuse, threats, and physical violence are harmful to staff or other patients (1).
In separate articles in Seminars in Dialysis, Balint and Friedman admonish nephrologists to try to identify and ameliorate underlying issues that can lead to these problematic behaviors. Examples of such issues include patient ignorance of the genesis of their renal failure and the reasons underlying their need for dialysis, medical and psychosocial factors making compliance difficult, and addiction (2,3). Both authors, however, conclude that for extremely disruptive behavior for which exhaustive efforts to address underlying causes have failed, dismissal of the patient is morally justified. They also note that two court cases—Brown v. Bower and Payton v. Weaver--have addressed the issue of the disruptive dialysis patient. In these cases the right of individual nephrologists to dismiss dialysis patients was upheld; however, hospitals were judged to have a continuing obligation to provide emergent dialysis care.
Oftentimes the ethical issues surrounding the disruptive dialysis patient are conceptualized in terms of duties such beneficence or respect for patient autonomy. Certainly physicians should work with staff to address and ameliorate the underlying conditions that might lead to disruptive behavior because these behaviors are often self-destructive in nature and can inhibit fully autonomous action. For those patients whose behaviors primarily harm self, physicians should provide education about the negative consequences of their actions but at the same time, understand that persons do not always use their free-will to further their own best interest. If a patient’s behavior becomes sufficiently harmful to others in the dialysis unit, then a nephrologist is ethically justified in taking steps to limit this harm that may ultimately lead to the dismissal of the patient. Certainly, when this occurs, the patient should be given appropriate notice (usually at least 30 days) and information about other dialysis units in the area. In most of these cases, a community obligation to continue dialysis will exist which may be met by acceptance into another dialysis unit, by providing dialysis in an acute care setting or by rotating the patient to different dialysis units in a community.
Another way to frame the issue of the disruptive dialysis patient involves focusing on the ideal of the good physician. Noncompliant or disruptive behaviors that may not rise to the level of causing harm to other patients or staff can still generate a great deal of anxiety and frustration. In these cases, it is natural for nephrologists to wonder why they should put up with such patients. In those frustrating moments, it is important for nephrologists to remember why we do what we do. We don’t take care of patients because they are polite or respectful or easy to work with. We take care of patients because they are sick and they need someone to take care of them. In the face of the vulnerability caused by disease, we promise to help—and this promise defines us (4). It also empowers us. In the face of difficult patients, we can steadfastly hold on to the ideal of the good physician and honor the promise of our profession by treating these patients with respect and dignity, striving to act in their best interests as much as they will allow us to do so. In the really difficult and exasperating times, it may not be empathy, sympathy, or a sense of duty to respect autonomy that keeps one oriented toward right action; rather, it may be a desire to live up to an ideal which if embodied gives meaning to our work by transforming it into something that is noble and good.
References
1. Hashmi A, Moss AH. Treating difficult or disruptive dialysis patients:practical strategies based on ethical principles. Nat Clin Pract Nephrol. 2008 Sep;4(9):515-20. Epub 2008 Jul 8. Review. PubMed PMID: 18612329. http://www.ncbi.nlm.nih.gov/pubmed/18612329
2. Balint J. There is a duty to treat noncompliant patients. Semin Dial. 2001 Jan-Feb;14(1):28-31. Review. PubMed PMID: 11208036.
3. Friedman EA. Must we treat noncompliant ESRD patients? Semin Dial. 2001 Jan-Feb;14(1):23-7. Review. PubMed PMID: 11208035.
4. Pellegrino, Edmund D., “Toward a Reconstruction of Medical Morality,” The American Journal of Bioethics, 6(2) (2006) 56-71.
