The Difficult Patient

On May 20, 2007, the Los Angeles Times published a frightening and sad story that described the last 90 minutes of a woman's life.1 This woman had been labeled a “complainer”—a difficult patient. The police returned her to the emergency department where she had been treated earlier after they found her outside another hospital yelling for help. This was her third visit in 3 days for abdominal pain. Upon arrival at the original emergency department where she had been treated a few hours earlier, a nurse told her there was nothing else that could be done for her, and she was placed in a wheelchair in the ED lobby. She fell out of the wheelchair and lay on the floor for 45 minutes, writhing in pain. One patient briefly asked her how she was doing. The janitor cleaned around her. A closed-circuit camera recorded her care.

After her boyfriend arrived in the emergency department and made an unsuccessful call to 911, he asked the police who were in the department for help. The police, alerted to a “disturbance” in the lobby, then stepped in. They discovered that the patient had an outstanding warrant and decided to take her to jail. Before she could be placed in a squad car, she experienced cardiac arrest. Despite resuscitation efforts in the emergency department, she was pronounced dead.

Acute pain continues to be the most frequent complaint documented for patients who come to the emergency department, but pain management is still often neglected.2 An analysis of 3785 patients with a diagnosis of abdominal pain and associated disorders found that the majority of patients did not receive any medication for pain relief.3

Pain is one of nature's most basic signs that something is wrong. Pain has both subjective and physiologic components that can be challenging to assess and manage. Patient response to pain can vary from being stoic—making the cause and source of pain hard to detect—to loud, with aggressive behaviors that oftentimes are difficult to contend with. No matter how it presents, pain is still an important sign.

Several factors have been identified that influence the management of patients who have been labeled as “complainers” or “difficult,” particularly when related to complaints of pain. These factors include noncompliance with prescribed follow-up treatment, aggressive behaviors, and rudeness to the staff, as well as patient attitude and manipulation of the staff to obtain medications, especially pain medications.4

Complaints about ED care are not uncommon. Reasons for complaints include misdiagnosis (real or perceived), staff attitude issues, inattention or perceived lack of caring, poor communication, increased waiting times, billing and related issues, and lastly, the ED environment.5 Complaints are frustrating because many times they arise from issues and events out of the emergency nurse's control. However, complaints of pain are still a sign that should not be ignored.

It seems obvious when reading this horrific tale that the manner in which the patient was complaining of acute pain should have alerted not just the emergency nurse but anyone who came in contact with the patient that there was a problem. Why did this not happen?

A study conducted by a group of nurses and a psychologist in Australia may lend some explanation.6 Interviews of emergency nurses and medical officers lasting 45 to 60 minutes were conducted to identify major and minor themes that reflected why or why not nurses and physicians did or did not respond to abnormal vital signs, for example, tachypnea and hypotension. This study found that care in the complex environment of the emergency department is influenced by human and environmental factors. These factors included workload, inadequate documentation, and patterns of communication, inexperience, stress, and lack of staff support.

Are we now in such a complex, stressful work environment that “signs” are ignored? Can any justification be brought forth that would explain what happened to this patient? What can be done to prevent this from happening again? Some steps suggested by Cronan5 seem almost too simple: pay attention to the patient/family; introduce yourself; make patients comfortable while they wait.

Manage the “signs.” Care for the “difficult “patient. This can be done through education about pain management and allowing emergency nurses to provide some initial medication as needed.2 More time has to be allotted to be able to interact with the “difficult” patient to discover what the problem or problems may be. Emergency care is complex and does require additional staffing, training in triage, and practice in critical decision making.

Emergency care requires empathy and understanding. A person who does not possess these traits, whether he or she be a nurse or physician, should consider a change. Needless, cruel deaths are not a legacy we should be a part of.