Chapter 15

Treating pain in a difficult patient may raise the challenge and lower the expectations from any analgesic intervention. In this section, the term difficult is applied to patients with behaviors, rather than symptoms, that are beyond the norm and that undermine treatment. Discussion of other difficult symptom presentations is beyond the scope of this chapter. Difficult patients who are in pain often are in conflict about whether or not they want care, want the care they are offered, or want pain. Groves has said, “Such patients simultaneously demand and reject care.” These patients may also simultaneously obtain and undermine treatment or flatter and frustrate their clinicians. In mild cases, they may strike a cord of uneasiness in their caregivers. In severe cases, caregivers may experience strong emotions such as fear and hate.

Some clinicians find it difficult to acknowledge or discuss patients who strike a negative chord in them. Often, this is because of the intrinsic conflict such patients raise with caregivers. Many clinicians would simply rather not dislike any patients. Disliking a patient is counter to what caregivers consciously strive to achieve—helping in every way. So, even discussing a difficult patient can make some clinicians feel uncomfortable, as if the patient is either being mistreated or ridiculed. Certainly, this may occur with certain individual clinicians in some situations. On the other hand, some patients clearly are difficult, have long histories of inciting strong negative reactions and difficult interactions with many health care providers, and place clinicians in untenable situations in which they ultimately feel bad. Not recognizing this phenomenon is a disservice to the patient. But it is also of paramount importance to recognize that most patients who make you suffer as a clinician are probably suffering much more. Patients with dysfunctional patterns of interactions with physicians usually have similar, if not worse, problems throughout the rest of their lives. Thus, the clinician’s discomfort is often just a small reflection of the patient’s much greater torment.

Although there is no easy formula for what to do in these difficult interactions, the common mistake is to miss opportunities in which commonsense adjustments can ameliorate problems and prevent escalation. Unfortunately, such difficult cases bring with them frustration and, often, even more severe emotional responses, which taken together diminish the clinician’s ability to bring common sense to bear. In such situations, it is critical to recognize dysfunctional patterns of patient and staff interactions as well as monitor one’s own internal reactions. By doing so, one can then apply greater awareness, deliberation, planning, patience, and caution to a difficult situation rather than acting from impulse or instinct. This perspective may make the clinician the only member of the treatment team able to change the tide of acrimony and reestablish effective treatment. What follows here is not new and is extensively taken from the work of James E. Groves, as well as Adler, Buie, and Maltsberger, who have published the seminal writings on this subject ...

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