| HOME | HELP | CONTACT US | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Department of Medicine, Division of Hematology-Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
Correspondence: Richard T. Penson, M.R.C.P., M.D., Instructor in Medicine, Hematology-Oncology, Cox 548, 100 Blossom Street, Boston, Massachusetts 02114-2617, USA. Telephone: 617-726-5867; Fax: 617-724-6898; e-mail: rpenson{at}partners.org
Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com
LEARNING OBJECTIVES
Top
Learning Objectives
Abstract
Presentation
Dialogue
Discussion
Conclusion
References
After completing this course, the reader will be able to:
|
ABSTRACT |
|---|
|
TopLearning ObjectivesAbstractPresentationDialogueDiscussionConclusionReferences |
|---|
Addiction among cancer patients on strong analgesics is a rare but difficult management challenge. The case is presented of a 28-year-old woman with breast cancer and painful bone metastases, suffering with dysfunctional social chaos and addicted to Percocet® (oxycodone and acetaminophen). Having broken the trust of her health care team, trust was rebuilt by incorporating the substance abuse clinic and enforcing a contractual agreement. With open and honest support, the team was able to both care for and empower the patient. Issues of trust, liability, opioid tolerance, and barriers to optimal analgesia for cancer pain are discussed.
Key Words. Oncology • Support • Psychosocial • Opioids • Morphine
|
PRESENTATION |
|---|
|
TopLearning ObjectivesAbstractPresentationDialogueDiscussionConclusionReferences |
|---|
Karen presented as a 28-year-old woman who had a 1-cm cancer of her breast. She had no bad prognostic features; lymph nodes were negative and the tumor was ER positive. We recommended adjuvant chemotherapy, which she received. She did reasonably well and was seen routinely for 4 years. On a scheduled visit she was found to have a mass in her breast. Fine-needle aspiration was negative. She was pregnant, in the first trimester, and noted to be more anemic than would be expected. However, on subsequent evaluation, she was noted to be having extensive pain and dyspnea. Investigation revealed bone and lung metastases. We recommended terminating the pregnancy and starting chemotherapy. She started weekly paclitaxel, and our psychiatry service started following her very closely and treated her with citralopram and clonazepam. All of her symptoms improved dramatically. Having completed chemotherapy, hormonal therapy was discussed with her and she agreed to bilateral salpingo-oophorectomy.
| What do you do with a patient who has real reason to be in pain but who abuses the medicine that you give her?
|
She subsequently had multiple admissions and many clinic visits. Admissions were for bone pain, possible phlebitis, and abdominal pain. None turned out to have a significant clinical component, but they were certainly very real problems for her. She also had one psychiatric admission, which she requested because of depression and anxiety. It became clear that she had poor family and social support, and that has been a major issue for us.
To give you an example of the problems we have had trusting her, she was seen in the office complaining of severe abdominal pain. She wanted to be admitted. If you were able to distract her, the abdominal examination was really unremarkable. It was difficult to get her admitted to the hospital that day because the hospital was full. Upon learning this, she suddenly decided that this was no longer an important problem, jumped out of the wheelchair that she’d been sitting in for the past 6 hours, and went home.
Clinical Nurse Practitioner: I’ve known this young lady since she started adjuvant chemotherapy 4 years ago. We’ve had a good working relationship over that time. She had wildly spreading disease before termination of pregnancy and initiation of chemotherapy. She had diffuse bony metastases, and I prescribed oxycodone and acetaminophen (Percocet®). Over the next several months, the enormity of her diagnosis, her prognosis, and the fact that she had lost her child became more and more significant to her. Her home situation is abominable. And I think she wanted someone to love and she wanted someone to love her back. We essentially took that from her to save her life, which she intellectually appreciated, but had a very difficult time appreciating emotionally. She had lost her child and she could no longer have children.
One day she called and said her brother had stolen her Percocet®. I gave her a prescription for 100 Percocet®. A couple of days later, she called back and said that her brother had stolen her pills again. So I wrote another prescription for another dose. Three weeks later, she said she’d been into the emergency room for some reason and had her pills stolen there. So I thought, "Okay, fine," and I wrote another prescription. The fourth time this happened, she said that her pocketbook had been stolen with her medications in it. I finally began to realize that perhaps I was being taken down a very long pathway with a chain around my neck. The team began to discuss the probability that there was a drug abuse problem.
By that time her pain was worse and she was on OxyContin® (controlled-release oxycodone hydrochloride). She paged me at home in the middle of the night saying, "I didn’t get my prescription filled today." We had arranged that I would give her a 1-week supply of her medication. That didn’t work well because she consumed a week’s supply of in 3 days, or supposedly consumed it. She has very poor judgment. She had a number of people living in her house and she had given the keys to a locked medicine safe to her mother and 15-year-old nephew. She is a sweet girl, but not terribly bright... although she’s bright enough to pull the wool over my eyes [laugh].
We were just starting to get things resolved when one of Karen’s friends called us. She was very irate because Karen had apparently accused her son of stealing her drugs from her medicine cabinet. This young boy had never been to Karen’s home, and this woman called me to tell me that she wanted me to be aware that Karen was selling her drugs. That broke the last remains of our trust. What do you do with a patient who has real reason to be in pain but who abuses the medicine that you give her? These issues have been plaguing us and have taken tremendous emotional and physical tolls. She’s a likable kid, but you realize that she’s manipulating you, and that makes you angry with yourself and frustrated at her.
I think she wants to take more responsibility now. She has gotten a medicine safe with a combination that only she knows. That’s a tremendous step. I feel I need to trust her again. She knows that she’s the one who’s going to blow it, not us. She is a time-consuming individual. You can’t ignore any symptom, because the one time we ignore it, it could be real. So we’re doing serial CT scans for abdominal pain and multiple chest x-rays for cough.
| As an oncologist, I can say that managing cancer pain when there are issues of substance abuse is among the most challenging types of pain control issues that we encounter.
|
In working with her, I’ve come to understand that when she starts talking about feeling ill or being in pain, you always have to ask how things are at home. When her home life is bad, it means that her emotional life is very chaotic and things are difficult. So we problem-solve very concretely about what she can do, and that helps her get by week to week. She is starting to internalize some of those things, and we now don’t have to do that in such a deliberate way as we did at the beginning.
Social Worker: I first met Karen during the admission in which her pregnancy was terminated. I met with her and her mother. They told me about her father, who had died of "bone cancer." He’d apparently died within 4 days of the diagnosis, within the past year. The whole idea of cancer again striking was incredibly anxiety provoking for the family.
They lived in a three-bedroom house with a large number of other adults. Karen’s mother works in a convenience mart, and in order to get messages to Karen, you pretty much have to call the mart and see if her mother’s at work. There’s also a brother who Karen describes as illiterate and retarded. He had a head injury, is impulsive, and is a substance abuser, mainly she thinks with pot, but possibly with pills and other things. She has a sister who works and lives in the house. At the time of her treatment, another sister was involved in a domestic violence incident with her husband. The husband was jailed, and they lost the house. The sister and her 15-year-old son became homeless, so they also moved into the house. Karen’s brother has a girlfriend who also lives with them. Karen’s brother’s girlfriend has her own mental illness problems. Karen considers her to be her best friend. A lot of the people in the household are on medication. A lot of them are on Clonazepam® and Percocet®, and it came to our attention that they were all trading. When someone ran out of something, they would say, "Hey I need some more of this, I’ll give you two of this if I can have two of that." It was incredibly difficult for us to know what the patient was taking and when she had taken it. She often didn’t even know!
Karen had an emotional breakdown on the anniversary of her father’s death, a couple of months after she had the surgery that took away any chance she had of becoming a mom. She is a person who struggles with identity issues. Before this, she worked and that was her identity. And then, when she couldn’t work, I think she invested her identity in being a mom, and then that was taken away from her. She has a limited capacity to express herself. She has little insight, and she quickly gets frustrated. I find that in order to work with her we have to set a lot of concrete boundaries, almost contracts, with her.
A strength is that Karen wants to be liked by the team. What we regard as manipulative behavior is her way of having her needs met, and we’ve come to understand that it is in part a need for social contact with us. It is clearly not the best way to get her needs met, so we’ve tried to redirect her in other ways, and she hasn’t had an admission for a while now.
The other thing that really helped occurred the day that Karen appeared at my office looking very strung out and shaky and with pressured speech. She told me that she had taken 84 Percocet® in 2 days and that she was feeling out of control. I spent the entire afternoon with her, talking with her and the team. At first, she insisted that she would not be admitted on a psychiatric admission, that she wanted a medical admission. That had been her way of getting relief before. She would come for a "hotel stay," get beefed up, and go home. This was a chaotic time for her. Because of the medical need for the pain meds, she wasn’t suitable for a detox[ification] program. In the course of that conversation with health providers who had known her for a long time, we were able to explain to Karen that, because she had come to us and started to tell us the truth, we were able to help her, that we had her best interests at heart, and that she could trust us. We wanted to help her get back a sense of control. In the course of time, we ironed out a lot of the very concrete interventions around how she would get her analgesics and medications.
| Our primary job is to ensure that we’re providing excellent cancer care for the patient.
|
During that admission, she talked a lot about her use of substances, and that she had previously had a problem with cocaine during her teens. She had ended that herself "cold-turkey." We also talked about some of the shame involved in being an addict. For about a 2- to 3-week period, she was able to do some of this work, and she avoided some of her old haunts. But every time she gets a boyfriend, it’s bad news, and it seems that she has a different boyfriend every week. The boyfriend who had been the father of the baby was in jail. He had been released at the time of diagnosis of recurrent disease and termination of pregnancy. She had become involved with him again, but he had another girlfriend. It was a soap opera. It is very easy to get involved in the story, and you then miss the bigger picture about what Karen’s telling you. The dysfunction becomes a smokescreen that goes on and on. At this point, her symptoms of anxiety and depression are minimal, and she seems to be functioning quite well.
Infusion Nurse: What I need to add to the story is that in the 8 months I have been treating her, she has never missed an appointment. What is striking is that having metastatic breast cancer in her 20s is probably fifth on her list of problems. When she comes to the clinic, we rarely discuss her disease. She’s a very open person and will chat about whatever comes to mind. I learned very quickly not to put her in the bay near the Catholic nun who is treated on the same day, as she turned beet red at some of the things Karen was talking about. We also have to control which single room she has chemotherapy in, because if she is near the nurses’ station, she will talk and talk and completely distract the closest nurse. She needs a lot of handholding. She often goes off on a tangent. So I say to her, "I have five minutes. What is it we really need to get through today?" And then we deal with another problem the following week.
|
DIALOGUE |
|---|
|
TopLearning ObjectivesAbstractPresentationDialogueDiscussionConclusionReferences |
|---|
Social Worker: You obviously had to establish some trust and set limits with her, and also with each other. What I haven’t heard is whether there’s been splitting among the staff about how they respond to her. Has that been an issue?
Clinical Nurse Practitioner: No. I think we know what we’re dealing with and I think we’re tight enough as a team that I haven’t been aware of any conflict among us.
Social Worker: Because she has involved so many health providers, we contracted specifically with her that there would be no secrets among her care providers. We explained that we would all be talking weekly about our interactions with her and that information she shared with one of us would be shared with the rest of the team. She agreed to that. There have been times when I’ve had to remind her of the contract. At times she’s distorted what we understood it to be. It’s taken a lot of work, but we’ve all stuck to it.
Substance Abuse Physician: We are very, very pleased that you asked us to see her and wish that we had the opportunity to see more patients earlier on to help you evaluate the situation. Then we can work out a potential treatment plan and give you advice on signals that you need to watch for. The signals were all there. You’ve already seen all the signals. But when you’re working so intimately with a patient, it’s very easy to miss the signals: a chaotic psychosocial home situation or a history of substance abuse or depression.
I have this long, long list now of the excuses for lost medication: The dog ate them, I dropped them down the toilet, I was walking down this street and someone mugged me and the only thing they took was my medication. We had a patient not very long ago who was pregnant, and she came in to be delivered and the tox[icology] screen was positive and she told this story: She was having some labor pains, and she was nervous about it so decided to spring-clean all her cabinets. There in the back of the cabinet was one little pill. And she didn’t know what it was, but she took it anyway. That’s the reason that she had a positive urine screen. Substance abusers can be very, very inventive. Consequently, from the beginning I tell patients there is no excuse that will enable me to prescribe medication outside this envelope, face to face, once a week, no telephone, no PRN, and only one prescriber. Of course, along the way Karen violated all the rules.
| Addressing the multiple dimensions of pain is a major part of holistic palliative care, but this realization has only slowly been adopted in oncology.
|
One of the most significant things about Karen was that she had no life, that her only goal, was pain relief. What a signal! That has to be part of the contract—get a life and have some functional existence. If they don’t have any of those goals that you can work for, I think you’re going to have trouble. We set up some cardinal rules (Table 1
). There must be a written contact before you even get started with narcotics.
|
Substance Abuse Physician: I think it’s a sign for a care provider when you start feeling responsible for their pain relief. Step back, why aren’t they being responsible for what’s happening? Why do they call you when you’re not here? It’s when that happens that you have conversations that start setting the ground rules.
Oncologist: Could a fentanyl patch be a better way to alleviate the pain? It must be hard to sell a fentanyl patch.
Substance Abuse Physician: There’s a gigantic market now for fentanyl patches. The going rate now is about 15–20 bucks a patch. We would strongly suggest not using fentanyl patches if you can in this kind of patient with substance abuse.
Oncologist: This person has so many problems, you can’t possibly try solving everything. How did you prioritize?
Social Worker: We had to do an exhaustive head-to-toe assessment. While we’re doing the medical assessment, a lot of the emotional needs and the scatterbrained things come up. Then we jointly prioritize.
Nurse Practitioner: Two very positive things have happened. We got a visiting nurse involved so that there was someone going into the home. It gave Karen more support, some more education about the medications, and also confronted some of her family’s misconceptions about the medication.
The other thing is that Karen made a good friend. She met someone at the hospital and they exchanged phone numbers, and she talks often about how they talk on the phone and there’s support there. She’s getting to a place now where she’s much more functional than she was when we started, so we can start working toward other goals.
Oncologist: Some of these patients with addictive personalities are particularly charming. Despite their problems, you actually enjoy being around them.
Oncologist: Did you suggest a support group like NA (Narcotics Anonymous)?
Nurse Practitioner: I talked to Karen a lot about whether a support group would be helpful. I strongly encouraged her to go to a meeting, but she refused. She said that she would be open to going to a meeting where people talked about depression, so we’ve been talking about that.
Social Worker: A lot of patients who get into trouble with prescribed narcotics don’t really see themselves as addicts and that really prevents them from engaging in that kind of group.
Chaplain: What has the team learned about the spiritual and religious dimensions of her life?
Social Worker: She’s talked more about the neighborhood that she would hang out in. But as far as a religious component to her family, that is one that has never been discussed. I don’t think she’s ever bought it up.
Infusion Nurse: In the initial assessment, I always ask, "Do you have religious thoughts and traditions? Do you believe in a spiritual power?" She told me she was a Catholic, she believed in God, but when I tried to go further with that in my assessment she was nearly nodding off, and I couldn’t get her to explain further.
| The common tension between reconciling one’s self with and distancing one’s self from pain is severely complicated when associated with substance abuse.
|
Nurse Practitioner: There’s only so far you can go with her. She clearly lets you know, by changing the subject, by nodding off, or by saying, "Oh I’m really tired." There are times when those windows do open, but they’re few and far between.
Social Worker: She needs to be in a very safe and secure place in order to do any of that intuitive work.
Oncologist: It sounds like Karen is an example of someone using her narcotic medicines to treat her sadness and her loss. I’m wondering, as a group, how common is it for our patients to use pain medicines to help carry them through, when it’s really an emotional pain?
Oncologist: I think it’s a common problem, sometimes we recognize it, and sometimes we don’t. If we can recognize it, we can deal with it, but sometimes, particularly when you’re seeing someone so frequently, you get sucked in, and it’s hard to stand back. If you were to see someone like this, not having seen them before, it’s often immediately obvious to you what they are doing. But when you see them over and over again, and live this life with them, I think you can lose objectivity.
Oncologist: The only time I feel some anger is in these situations in which the patient is selling the drugs that I gave them. That makes me angry. That is where I set my limit. If you’re selling it, you’re not going to get anymore.
Oncologist: With people who have a history of substance abuse and develop cancer pain, my attitude is—they win. I’ll give them as much narcotic as they want. We’ll do everything we can to get them out of pain, and if they use it to help medicate a depression, as long as they do it in a responsible way, that’s okay. I think I might be more successful treating their real depression with antidepressant drugs.
Oncologist: I don’t like the idea of giving them whatever they need, because I don’t think I really know what they need. I have to understand it before I can really prescribe for them appropriately.
Oncologist: One of things that happened in this case that is wonderful, is that you as a team didn’t ignore her symptoms. I think it’s absolutely critical that we don’t fail at the other extreme and ignore pain and symptoms in these people.
Oncologist: Our primary job is to ensure that we’re providing excellent cancer care for the patient.
|
DISCUSSION |
|---|
|
TopLearning ObjectivesAbstractPresentationDialogueDiscussionConclusionReferences |
|---|
WHO Guidelines on Cancer Pain
Opioids are the current standard of care for the treatment of moderate or severe nociceptive (i.e., in response to noxious stimuli) pain. The World Health Organization (WHO) three-step analgesic ladder has proven to be highly effective for the management of cancer pain (Fig. 1) [1]. Opioids should be prescribed with regular doses by the clock to ensure pain relief and prevent breakthrough pain. Long-acting opioids are preferable to short-acting preparations, and oral administration is the best and cheapest route and should be used when ever possible [1].
|
| There are early signs of dependency that can be watched for.
|
These guidelines are relatively easy to follow, and "the greatest improvements in the quality of life for cancer patients and their families [can] be effected by the implementation of the current knowledge of pain and symptom control" [2]. Frustratingly, the medical profession is still not fully medicating pain. "The medical use of opioids does not create drug addicts" is a message that does not seem to have reached the general public nor the general medical profession [1, 3].
Barriers to effective cancer pain management remain. Patients may be reluctant to report pain or reluctant to take opioids. However, physicians still evidence poor appreciation for the basic principles of treating cancer pain, and a lack of prescriber education seems be the main reason for the undertreatment of cancer pain [4]. Prescribers do not fully understand tolerance to opioid analgesia and fail to recognize that doses should be driven by pain and not by prognosis [5]. One study of junior doctors demonstrated that many of them were unable to convert an i.v. morphine dose to a suitable oral dose, and only half of the respondents realized that a cancer patient has less than a 1% chance of becoming addicted to their pain medications [6]. Underdosing is common [7]. Dame Cicely Saunders formulated a concept of ‘total pain’ to include physical, psychological, social, emotional, and spiritual elements [8]. Addressing the multiple dimensions of pain is a major part of holistic palliative care, but this realization has only slowly been adopted in oncology. These simple issues are far more common barriers than esoteric challenges such as potential hyperalgesic states accompanying opioid dependence [9], or pseudoaddiction, an iatrogenic syndrome resulting from poorly treated pain [10].
Cancer Pain and Addiction
In the chronic pain patient taking long-term opioids, tolerance (requirement for increased dose to produce the same effect) and physical dependence (receptor tachyphylaxis that results in the development of a withdrawal syndrome when the drug is withdrawn) are expected. The maladaptive behavior changes of addiction are not expected [11]. Substance abuse is suggested by: A) loss of control of drug use (no partially filled medication bottles (or no bottles), frequent extra doses, poor compliance); B) adverse consequences (legal, work, social, family) despite obvious harm; C) drug-seeking behavior, and D) abuse of other drugs or contact with the drug culture [11, 12]. A notable report in 1980 found evidence for addiction in only four of 11,882 patients, with no prior history of addiction, on narcotics for pain [13]. This finding has been supported by later studies [6] and by surveys of drug "diversion," showing that drugs sold on the street very rarely come from chronic pain sufferers [14]. However, prejudice and myth remain despite considerable experience and research suggesting that in appropriately selected patients, opioids have a low morbidity and low addiction potential [10, 15]. But it is not just physicians who suffer with prejudice about the addictive potential of opioids. In one fascinating study of patients’ beliefs about opioids, 40% of cancer patients believed that a quarter of their peers were addicted to drugs [16]. In less developed countries, opioids are still often not available for pain relief because of excessive regulations imposed to prevent abuse [17]. Yet a report on 1,723 patients followed in Calicut, India, who were treated for pain with oral morphine over 2 years, failed to identify any instances of abuse [17].
In addicts, methadone may be an important alternative to other opioids, because it has no known active metabolites and less side effects [18]. It is well absorbed by oral and rectal routes, and also has the advantage of very low cost. Limitations are its long, unpredictable half-life, which can result in accumulation and toxicity in some patients, and increased potency with protracted use makes rotation to other opioids problematic.
Pain is a particularly subjective symptom. Only the person experiencing pain can report its character and intensity. The common tension between reconciling one’s self with and distancing one’s self from pain is severely complicated when associated with substance abuse. Rather than relentlessly pursuing psychotropic drug abstinence as the treatment goal, the physician should seek restoration of function as the primary treatment goal for the chronic pain patient [11].
Teams
Caring for cancer patents with pain has rightly become a multidisciplinary task. Continuity and flexibility demand good communication. In Karen’s case, caught in the tension between inadequately treating pain and fuelling drug abuse, open communication was formalized in a written contract with proactive "on-course" correction. Patients like Karen require time and effort. Successfully medicating pain and ensuring minimal abuse will almost always require that the substance abuse team be involved. And the oncology team used the fragile relationship of trust that had built up in order to show her how to use her autonomy in a more productive way.
Although the staff liked Karen, they conceded that they found her very difficult to care for. In Taking Care of the Hateful Patient, Groves described how negative feelings about patients can help staff define what patients most need [19]. Groves described four types of patients that doctors learn to dread: dependent clingers, entitled demanders, manipulative help-rejecters, and self-destructive deniers [19].
| Difficult patients create dissonance in the medical setting, and a psychiatric consultant can help relieve this distress in the patient and in the staff.
|
Karen’s profile most closely fits that of a "dependent clinger." She is someone who is not only in need of reassurance, but also cries out for "explanation, affection, analgesics, sedatives and all forms of attention imaginable" [19]. While quite open in expressing her neediness, her needs were often expressed in the language of maladaptive behaviors. It is common for dependent clingers to have a sense of quenchless need, and they misperceive physicians and other caregivers as inexhaustible sources of caring. The physicians, on the other hand, often develop a response of "weary aversion." The doctor becomes the inexhaustible mother figure to the patient, while the patient becomes the unwanted and sometimes hated child in the doctor’s eyes.
There are early signs of dependency that can be watched for. These patients often show too much gratitude at the outset. They often idealize their caregivers followed, at the first barely perceptible hint of rejection, by devaluation and affect-laden outbursts of emotional pain. It often helps early on to let these patients know tactfully and firmly that the doctor is not all good, that there are limitations to his knowledge, expertise, availability, and empathy. Psychiatric referral early in the treatment can often be helpful, because many of these patients have cluster B, "dramatic, emotional, erratic" personality disorders. These include antisocial, borderline, histrionic, and narcissistic personalities. Often these individuals have suffered deprivation and even abuse in childhood, setting in motion a spiraling toward maladaptive coping styles and comorbid mood disorders. Depression, including dysthymia and major depression, and posttraumatic stress disorder are common findings, and Karen could be showing signs of a "masked depression" with somatoform pain complaints.
Substance abuse is often associated with personality disorders and with mood disorders. Karen’s chaotic family and social history combined with her history of substance abuse put her at risk for worsening of her abuse during her severe loss experiences and their aftermath. Losing one’s father to cancer, getting the diagnosis of breast cancer at age 28, having a recurrence of it with metastases to bone during a pregnancy, and having to terminate the pregnancy along with any chance of having another baby are grave loss experiences by anyone’s measure. Such tragic losses have a strong tendency to rekindle separation anxiety and the fear of loss of attachment in the future. From our earliest developmental moments, our ability to transition through our fears of being separated to a state of secure individuation is aided and abetted by our basic trust in human objects we can securely attach to. Thus, as a toddler, we benefit from the realization that we can rely on our mothers even when they are out of sight. When children grow up in chaotic households, insecure attachments are more likely to occur. When these individuals face crises in their lives, they have difficulties with basic trust. This can lead to excessive, clinging attachment and dependency. However, dependency can progress to a distasteful sense of feeling engulfed, leading to the need to show independence. This behavior usually becomes maladaptive in nature. Then, with distance from the caregiver, comes a foreboding sense of feeling abandoned, driving the patient back again looking for solace.
The physician or caregiver must try to avoid getting on the same oscillating wavelength as the patient. Consistency in caring is key, all the while pointing out that one is human—not all bad but also not all good, therefore there is always going to be disappointment as there is in any relationship. There is often occasion to do limit setting—a three-stage process in which the unacceptable behavior is pointed out to the patient, the reason why it is unacceptable is discussed, and a healthy alternative is given. This should be done in a consistent manner because inconsistency breeds mistrust. The same principle holds in developing patient "contracts" as was done in Karen’s case. Karen’s trust of the team has improved with limit setting and the contracting that’s been done. The benefit that must always be implicit in the relationship is that the patient will no longer feel the threat of abandonment as he or she participates in a consistent relationship—one where behavior has consistent consequences.
| Trust allows the development of a more meaningful clinical relationship. However, this is challenged when trust is repeatedly breeched.
|
Other points are worth noting. Opiates are well known to reduce the separation cry of animals. We know that animal mothers who have morphine applied to an area of their brains called the anterior cingulate no longer respond to the cries of their offspring. Karen may certainly be using her narcotics to treat the emotional pain of her loss experiences, particularly that of her unborn child—"someone to love and someone to love her" as her nurse practitioner put it. So, in a way, she may be self-treating her depression with its emotional pain, with narcotics. Antidepressants are clearly a better choice to consider for this indication. This is another reason why a patient with her family history and her personal history of risk factors for depression and substance abuse should have psychiatric and pain evaluations early, before caregiver frustration sets in and such evaluations may be perceived as punishments.
There is also always the question of subtle brain dysfunction in patients like Karen, and examining for soft neurological signs of frontal lobe dysfunction or attention deficit symptoms should be part of the evaluation of a person like this.
When confronting a difficult patient, certain rules can be helpful. First, acknowledge the genuine stresses in the patient’s situation. Stay away from trying to dismantle needed defenses, even if they are primitive. Try not to overstimulate the patient’s desire for closeness or propensity for rage. Avoid confronting narcissistic entitlement and instead appeal to it by repetitiously saying, "You deserve the best medical care we can give you, and that is why we are recommending A, B, and C." "And part of the best treatment you are entitled to involves getting our educated medical plan which includes certain guidelines," whereupon limit setting and contracting can be done [20].
Difficult patients create dissonance in the medical setting, and a psychiatric consultant can help relieve this distress in the patient and in the staff (Table 2) [19].
|
| What happens when someone has never learned to trust others for the support that they need to meet the challenge?
|
However strongly you may feel that patients who repeatedly "cry wolf" may deserve more of the blame for a missed diagnosis or medical error, when cases go to litigation, courts assign physicians a greater responsibility for preventing untoward consequences [personal communication, Robert Hanscom, J.D., Director of Loss Prevention of the Risk Management Foundation, Harvard Medical Institutions, Cambridge, MA]. While patients clearly have a responsibility to follow up on a physician’s recommendations, a patient who has identified herself as being noncompliant shifts yet more responsibility to the physician. A physician’s awareness of noncompliant behavior colors the fiduciary relationship and may create more liability. The physician is not "off the hook" because of the patient’s known poor compliance. Actively trying to sway the patient with education and logical argument and positively reinforcing the importance of the change may mitigate noncompliant behavior. The reasons for noncompliance should be established, explored, and challenged. Documentation is of the utmost importance, and verbal encouragement should be reinforced with letters to the patient outlining the treatment or management plan. If the relationship is irretrievable, the physician is expected to document a plan in the chart, notify the patient by certified mail with the specific reasons for the failure of the relationship, and propose a clear interim medical action plan. Physicians are expected to provide ongoing medical care for a fixed, typically 30-day, period and emergency care for a further 15 to 30 days.
It is often hard not to take breeches of trust personally. Understanding the origins of the patient’s maladaptive behaviors can help. The seriousness of cancer as a separation challenge of the highest order puts one’s coping skills to the ultimate test. What happens when someone has never learned to trust others for the support that they need to meet the challenge?
Dealing with a dishonest and manipulative patient is a challenge, and our evaluation is fallible. Even with all the information and carefully listening for the "music" of nonverbal cues, we may misinterpret aggressive or defensive responses. Table 2
lists interventions: a consistent message, limit setting, contracting. Early psychiatric consultation is often appropriate. Avoid punitive behaviors in words or actions in response to a patient’s acting out. In many cases, patients are doing the best they can in the only way they know how. Even when patient behavior becomes egregious enough to warrant termination of care and referral, the old adage that tells us to hate the behavior but love the person, can hasten our forgiveness, which not only benefits the ones we forgive, but also ourselves.
|
CONCLUSION |
|---|
|
TopLearning ObjectivesAbstractPresentationDialogueDiscussionConclusionReferences |
|---|
|
REFERENCES |
|---|
|
TopLearning ObjectivesAbstractPresentationDialogueDiscussionConclusionReferences |
|---|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | CONTACT US | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| THE ONCOLOGIST | STEM CELLS | CME | ALPHAMED PRESS JOURNALS |
