1 Nature clinical practice. Nephrology 2008 Vol: 4(9):515-520. DOI: 10.1038/ncpneph0877

Treating difficult or disruptive dialysis patients: practical strategies based on ethical principles.

For more than a decade, dialysis units have had to contend with an increasing number of difficult or disruptive dialysis patients. These individuals present a spectrum of behaviors, ranging from those that harm only themselves to those that physically endanger dialysis staff. Such behaviors can interfere with the ability of the dialysis staff to care for the patient in question and for other patients; in addition, threats or actual physical abuse jeopardize the health and safety of both patients and staff. In this Review, we discuss how the application of ethical principles can assist dialysis staff to balance their ethical obligations to disruptive and difficult patients with those to other patients and staff, and to establish policies and strategies for the treatment of these challenging patients. This approach also allows health-care professionals to identify the limited situations in which involuntary patient discharge from a dialysis unit is ethically justified.

Mentions
Altmetric
References
  1. Forum of ESRD Networks (2005) Decreasing Dialysis Patient-Provider Conflict (DPC) Project. [Link (accessed 31 March 2008) , .
  2. Simon JR et al. (1999) The difficult patient. Emerg Med Clin North Am 17: 353-370 , .
    • . . . The difficult or disruptive patient is defined as one who impedes the clinician's ability to establish a therapeutic relationship.2 Verbal and physical abuse, nonadherence to medical advice, and substance abuse are characteristic features of a difficult or disruptive dialysis patient.3 . . .
    • . . . The medical literature on difficult or disruptive dialysis patients has become extensive;1, 2, 3, 4, 5 however, dialysis units are not often adequately prepared to deal with these individuals.3 Dialysis staff should be aware that there is a whole spectrum of difficult or disruptive dialysis patients who require different responses.4, 5, 7 In the hope of improving care for all patients receiving dialysis, this Review will discuss ethical principles and practical strategies for treating difficult or disruptive dialysis patients. . . .
    • . . . In a 2000 survey completed by 203 dialysis unit caregivers, approximately 69% of the respondents indicated that their facilities had witnessed an increase in situations arising from difficult or disruptive patients within the previous 5 years.2 Almost half (49%) of the participants said that they were not adequately trained to deal with situations involving a difficult or disruptive patient, and 40% of dialysis facilities where the participants worked lacked a written policy for such situations.2 This lack of written policies and of staff training can lead to escalation of situations caused by difficult or disruptive patients, and might even lead to inappropriate discharge of a patient from dialysis. . . .
  3. King K and Moss AH (2004) The frequency and significance of the "difficult" patient: the nephrology community's perceptions. Adv Chronic Kidney Dis 11: 234-239 , .
  4. Johnson CC et al. (1996) Working with noncompliant and abusive dialysis patients: practical strategies based on ethics and the law. Adv Ren Replace Ther 3: 77-86 , .
    • . . . The medical literature on difficult or disruptive dialysis patients has become extensive;1, 2, 3, 4, 5 however, dialysis units are not often adequately prepared to deal with these individuals.3 Dialysis staff should be aware that there is a whole spectrum of difficult or disruptive dialysis patients who require different responses.4, 5, 7 In the hope of improving care for all patients receiving dialysis, this Review will discuss ethical principles and practical strategies for treating difficult or disruptive dialysis patients. . . .
  5. Sukolsky A (2004) Patients who try our patience. Am J Kidney Dis 44: 893-901 , .
  6. Orentlicher D (1991) Denying treatment to the noncompliant patient. JAMA 265: 1579-1582 , .
    • . . . Mere nonadherence should not, therefore, lead to denial of treatment by a physician.6 The nephrologist or other clinician should consider their ethical and legal obligations towards a patient who requires the life-sustaining treatment of dialysis.14, 16 In the Brown versus Bower ruling of 1987, a hospital that received federal funds was required by law to provide dialysis treatment to a patient whose behavior was difficult and disruptive.16 However, the attending nephrologist was not required by the ruling to resume the physician–patient relationship. . . .
    • . . . A difficult or disruptive patient might make decisions that are harmful to himself or herself, for example not adhering to the prescribed diet or medication.5 Even though such behavior can cause distress to a health-care provider, it should not be a reason for involuntary discharge from a dialysis facility.1, 6 Some patients have psychological, social, or financial problems that restrict control over their actions.6 However, when the actions of a difficult or disruptive patient become harmful to other patients, respect for autonomy of the difficult or disruptive patient is overridden by competing moral obligations to other patients.10 . . .
  7. Levinsky NG et al. (1999) What is our duty to a "hateful" patient? Differing approaches to a disruptive dialysis patient. Am J Kidney Dis 34: 775-789 , .
  8. Mid-Atlantic Renal Coalition (1994) Working with noncompliant and abusive patients. [Link (accessed 14 May 2008) , .
  9. Rau-Foster M (2001) The dialysis facility's rights, responsibilities, and duties when there is conflict with family members. Nephrol News Issues 15: 12-14 , .
  10. Schwartz M and Batson H (2000) Understanding the psyche of the disruptive patient in the dialysis facility. Nephrol News Issues 14: 40-43 , .
  11. Johnstone S et al. (1997) The use of mediation to manage patient-staff conflict in the dialysis clinic. Adv Ren Replace Ther 4: 359-371 , .
  12. Miller RB (1995) Treating the disruptive patient. Nephrol News Issues 9: 39-40 , .
  13. Baskin S (1994) Ethical issues in dialysis. Guidelines for treating the disruptive dialysis patient. Nephrol News Issues 8: 43, 50 , .
    • . . . The wellbeing of a difficult or disruptive patient needs to be considered as long as the patient is not abusive.13 When the patient becomes physically or verbally abusive, the wellbeing of other patients and dialysis staff can be compromised . . .
    • . . . The principle of justice demands that health-care providers treat everyone, including a difficult or disruptive patient, fairly.13 An abusive patient might feel that he or she is being treated unfairly if denied treatment . . .
  14. California. Court of Appeal, First District, Division 1 (1982) Payton v. Weaver. Wests Calif Report 182: 225-231 , .
    • . . . Mere nonadherence should not, therefore, lead to denial of treatment by a physician.6 The nephrologist or other clinician should consider their ethical and legal obligations towards a patient who requires the life-sustaining treatment of dialysis.14, 16 In the Brown versus Bower ruling of 1987, a hospital that received federal funds was required by law to provide dialysis treatment to a patient whose behavior was difficult and disruptive.16 However, the attending nephrologist was not required by the ruling to resume the physician–patient relationship. . . .
  15. Baines LS and Jindal RM (2000) Non-compliance in patients receiving haemodialysis: an in-depth review. Nephron 85: 1-7 , .
    • . . . Ethical principles apply as much here as they do to the difficult or disruptive patient,15 and dialysis staff have to use their judgment to balance the implementation of such principles between these groups of people (Table 1). . . .
  16. Brown v. Bower, No. J86-0759(B) (SD Miss Dec 21, 1987) , .
    • . . . Mere nonadherence should not, therefore, lead to denial of treatment by a physician.6 The nephrologist or other clinician should consider their ethical and legal obligations towards a patient who requires the life-sustaining treatment of dialysis.14, 16 In the Brown versus Bower ruling of 1987, a hospital that received federal funds was required by law to provide dialysis treatment to a patient whose behavior was difficult and disruptive.16 However, the attending nephrologist was not required by the ruling to resume the physician–patient relationship. . . .
  17. Lundin AP (1995) Causes of noncompliance in dialysis patients. Dial Transplant 24: 174-176 , .
    • . . . Finding out the cause of difficult or disruptive behavior is important, in order to improve communication with the patient and to identify the appropriate response.17 Difficult or disruptive behavior can occur for any of the following reasons. . . .
  18. Department of Health and Human Services (2008) Medicare and Medicaid Programs: Conditions for Coverage for End-Stage Renal Disease Facilities. [Link (accessed 15 May 2008) , .
Expand