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SEPTEMBER 2008 VOL 4 NO 9 NATURE CLINICAL PRACTICE NEPHROLOGY 515

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SUMMARY

Treating difficult or disruptive dialysis patients:practical strategies based on ethical principlesAdnan Hashmi and Alvin H Moss*

INTRODUCTION

In recent years, the dialysis patient populationhas grown larger and more diverse.1At the sametime, dialysis units are facing a growing numberof patients who disrupt the smooth functioning ofthe unit and exhibit behavior to which dialysisstaff may be unsure how to respond. Theseindividuals interfere with the ability of dialysisstaff to care not only for them, but also for other

patients in the unit. In this article, such indi-viduals will be referred to as difficult or disrup-tive dialysis patients. The difficult or disruptivepatient is defined as one who impedes the clini-cians ability to establish a therapeutic relation-ship.2Verbal and physical abuse, nonadherenceto medical advice, and substance abuse arecharacteristic features of a difficult or disruptivedialysis patient.3

The medical literature on difficult or disrup-tive dialysis patients has become extensive;115however, dialysis units are not often adequatelyprepared to deal with these individuals.3Dialysisstaff should be aware that there is a whole spec-trum of difficult or disruptive dialysis patientswho require different responses.4,5,7 In thehope of improving care for all patients receivingdialysis, this Review will discuss ethical principlesand practical strategies for treating difficult ordisruptive dialysis patients.

A GROWING PROBLEM

Since 2001, conflicts between difficult or disrup-tive dialysis patients and their caregivers havebeen recognized as a growing problem in the US

by the end-stage renal disease (ESRD) networks,the Centers for Medicare and Medicaid Services,and the ESRD health-care provider commu-nity.1 In 1994, ESRD Network 5 (The Mid-Atlantic Renal Coalition) reported that it hadbeen contacted by its facilities two or threetimes regarding difficult or disruptive dialysispatients. In 2007, the same network reported49 contacts from its facilities related to difficultor disruptive dialysis patients and involuntarytransfers and discharges of such individuals.

For more than a decade, dialysis units have had to contend with anincreasing number of difficult or disruptive dialysis patients. Theseindividuals present a spectrum of behaviors, ranging from those thatharm only themselves to those that physically endanger dialysis staff. Such

behaviors can interfere with the ability of the dialysis staff to care for thepatient in question and for other patients; in addition, threats or actualphysical 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 anddifficult patients with those to other patients and staff, and to establishpolicies and strategies for the treatment of these challenging patients.This approach also allows health-care professionals to identify the limitedsituations in which involuntary patient discharge from a dialysis unit isethically justified.

KEYWORDS dialysis, difficult patient, disruptive patient, ethical, nonadherence

A Hashmi is a Nephrology Fellow at West Virginia University Hospital andAH Moss is a Professor of Medicine in the Section of Nephrology at the WestVirginia University School of Medicine, Morgantown, WV, USA.

Correspondence*Center for Health Ethics and Law, West Virginia University School of Medicine, PO Box 2022,

Morgantown, WV 26506-9022, USA

[email protected]

Received7 April 2008 Accepted 20 May 2008 Published online8 July 2008

www.nature.com/clinicalpractice

doi:10.1038/ncpneph0877

REVIEW CRITERIAMaterial for this Review was found by searching PubMed using the termsdisruptive dialysis patient, noncompliant dialysis patient, hateful dialysispatient, difficult dialysis patient, and ethics in dealing with difficultdialysis patients. A manual search was also conducted of reference lists in

key articles.

SUMMARY

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These contacts comprised the majority (75%)of the contacts the Network received from itsfacilities during that year. Difficult or disrup-tive dialysis patients are also the most commonreason for other ESRD Networks to be contactedby their dialysis facilities (R Bova-Collis,personal communication).

In recognition of the increasing numberof difficult or disruptive dialysis patients, theESRD community has come together to under-take the Decreasing Dialysis PatientProviderConflict (DPC) Project, which is funded by theCenters for Medicare and Medicaid Services and

coordinated by the Forum of ESRD Networks.The goal of the DPC Project is to improve staffpatient relationships and create safer dialysisfacilities by increasing awareness of patientprovider conflict and improving staff skillsto reduce its occurrence; the Project has alsocreated a common language to describe suchconflict. The final report of the DPC Projectwas released in June 2005, and it concludedthat dialysis providers who have taken the stepsnecessary to fulfill their ethical obligations and

to avoid the illegal abandonment of patients havethe legal authority to refuse to treat patients who

jeopardize the safety of others by acting violentlyor being physically abusive. The impact of thisreport and the training manual that was alsoproduced by the DPC Project to aid the resolu-

tion of conflicts that could lead to discharge ofpatients from dialysis units1remain unclear.In a 2000 survey completed by 203 dialysis

unit caregivers, approximately 69% of therespondents indicated that their facilities hadwitnessed an increase in situations arisingfrom difficult or disruptive patients withinthe previous 5 years.2Almost half (49%) of theparticipants said that they were not adequatelytrained to deal with situations involving a diffi-cult or disruptive patient, and 40% of dialysisfacilities where the participants worked lacked

a written policy for such situations.

2

This lackof written policies and of staff training canlead to escalation of situations caused by diffi-cult or disruptive patients, and might evenlead to inappropriate discharge of a patientfrom dialysis.

THE SPECTRUM OF DIFFICULT

OR DISRUPTIVE BEHAVIOR

The spectrum of difficult or disruptive behaviorin dialysis patients ranges from behavior thatharms only the patient in question to behaviorthat endangers other patients and staff inthe dialysis unit.3 Box 1 provides examplesof behavior throughout the spectrum. At theless-severe end of the spectrum, an exampleof behavior that jeopardizes only the patientsown health and wellbeing is signing out againstmedical advice before completing the dialysissession.5A second category of behavior is thatwhich puts the safe and efficient operationof the facility at riskfor example, showingup late for dialysis and demanding treatmentimmediately, thereby disrupting the schedulefor other patients.5At the far end of the spec-

trum is behavior that places the health andsafety of others at risk through physical or verbalabuse, or intimidation or threats to staff orother patients.5

The first step in managing a difficult or disrup-tive dialysis patient is to determine where thepatients behavior fits on the spectrum, as thiswill assist dialysis staff to determine their duty tothe patient in question versus their duty to otherpatients, based on the ethical principles outlinedin the following section.

Box 1 Examples of the spectrum of difficult or

disruptive patient behavior in the dialysis unit.5,7

Behavior harmful to the difficult or disruptive patient

only

Nonadherence to dialysis prescription (i.e.

missing sessions or signing off sessions early)

Nonadherence to diet

Nonadherence to medications

Improper care of dialysis access

Proscribed behavior in dialysis unit (e.g. eating

while on dialysis)

Behavior harmful to the efficient operation of the

dialysis unit

Late arrival for scheduled treatment

Requiring unscheduled extra treatments for

dyspnea triggered by nonadherence to fluid

restriction

Filing unsubstantiated complaints to State

Health Department

Filing a grievance with the end-stage renal

disease network against the dialysis unit

Behavior harmful to other patients and/or staff

Verbal abuse, threats or intimidation

Physical abuse

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ETHICAL PRINCIPLES IN RESPONDING

TO A DIFFICULT OR DISRUPTIVE PATIENT

Difficult or disruptive behavior from a dialysispatient has an adverse effect on the relationshipbetween the patient and the health-care provider.1However, health-care professionals have a moralobligation to deal with the difficult or disruptivepatient in a broader context of protecting andpromoting the patients rights and wellbeing.Mere nonadherence should not, therefore, lead todenial of treatment by a physician.6The nephrolo-gist or other clinician should consider theirethical and legal obligations towards a patientwho requires the life-sustaining treatment ofdialysis.14,16In the Brown versus Bower rulingof 1987, a hospital that received federal fundswas required by law to provide dialysis treatmentto a patient whose behavior was difficult anddisruptive.16However, the attending nephrolo-gist was not required by the ruling to resume thephysicianpatient relationship.

At the same time as promoting the best inter-ests of a disruptive or difficult patient, dialysisstaff have to safeguard the interests of otherpatients and of themselves. Ethical principlesapply as much here as they do to the difficult

or disruptive patient,15and dialysis staff have touse their judgment to balance the implementa-tion of such principles between these groups ofpeople (Table 1).

Respect for autonomy

The ethical principle of respect for autonomyrequires health-care professionals to respect anindividuals right to make his or her own deci-sions. As Table 1 indicates, therefore, dialysisstaff should continue to provide dialysis to a

nonadherent patient who continues to request

dialysis and does not interfere with the opera-tion of the dialysis unit. On the other hand, whena dialysis patient who is on the first shift of thedialysis schedule continually shows up late despiterepeated warnings and delays dialysis for patientson subsequent shifts in the same dialysis chair,the disruptive patients right to remain on thefirst shift needs to be balanced against the rightsof the patients on the subsequent shifts to starttheir treatments on time. In such a situation, thedialysis unit is ethically justified in movingthe disruptive patient to the last shift of the dayso that no other patients or staff will be inconve-nienced if the disruptive patient is late for treat-ment. Since continued dialysis is beneficial forthe difficult or disruptive patient, the dialysis unitshould still continue to provide it to the patient.

A difficult or disruptive patient might makedecisions that are harmful to himself or herself,for example not adhering to the prescribed dietor medication.5Even though such behavior cancause distress to a health-care provider, it shouldnot be a reason for involuntary discharge froma dialysis facility.1,6Some patients have psycho-logical, social, or financial problems that restrict

control over their actions.6 However, whenthe actions of a difficult or disruptive patientbecome harmful to other patients, respect forautonomy of the difficult or disruptive patientis overridden by competing moral obligations toother patients.10

Beneficence

The principle of beneficence requires health-care professionals to promote the wellbeingof all patients. The wellbeing of a difficult or

Table 1 Net balance of staff duties to a difficult or disruptive dialysis patient and to other patients and staff.a

Patient behavior Ethical principle

Respect for autonomyb Beneficencec Nonmaleficenced Justicee

Nonadherent, causing noharm to others

+ + + +

Nonadherent, harms andinconveniences others + +

Verbally abusive

Physically abusive

a+ indicates that duty to the difficult patient prevails; indicates that the duty to the difficult patient should be balanced withthe duty to others; and indicates that the duty to others prevails over the duty to the d ifficult patient.bRespect for autonomyrequires health-care professionals to respect an individuals right to make his or her own decisions. cBeneficence requireshealth-care professionals to promote the wellbeing of all patients. dNonmaleficence denotes the obligation of health-careprofessionals to avoid harming patients. eJustice implies that everyone, including the disruptive patient, must be treated fairly.

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disruptive patient needs to be considered as longas the patient is not abusive.13When the patientbecomes physically or verbally abusive, thewellbeing of other patients and dialysis staff can

be compromised. Because of the detrimentaleffect of such behavior on the autonomy andwelfare of other patients, the duty to othersprevails over the duty to the difficult or disruptivepatient in such a situation.

NonmaleficenceThe principle of nonmaleficence obliges health-care professionals to refrain from harmingpatients, which includes not letting a difficultor disruptive patient harm other patients ordialysis staff by his or her actions. Examplesof harmful behavior to other patients andstaff include not only verbal or physical abusedirected at an individual, but also screamingin the dialysis unit, damaging dialysis equip-ment, and destroying or removing medicalrecords.5 These behaviors need to be docu-

mented, and the dialysis unit should set limitson such behavior and give warnings about theconsequences of failing to comply with unitpolicies.8When a patients behavior is poten-tially harmful to others, the duty of ensuringnonmaleficence is towards others. On theother hand, if a difficult or disruptive patientsbehavior is not harmful to others, the patientshould be protected from harm.

Justice

The principle of justice demands that health-care providers treat everyone, including a diffi-cult or disruptive patient, fairly.13An abusivepatient might feel that he or she is being treatedunfairly if denied treatment. On the other hand,it is unfair for other patients and dialysis staff toface any kind of abuse from a difficult or disrup-tive patient. In such a situation, duty towardsothers prevails over duty to the difficult ordisruptive patient.

Professional integrity

The ethical principle of professional integ-rity comes into play when difficult or disrup-

tive patients create conflict in the dialysis unit.Physicians and nurses are required to putpatients interests ahead of their own and to actin a manner consistent with the highest valuesof their profession at all times, including whendealing with difficult or disruptive patients,even though they might prefer not to take anyaction. All the patients in a dialysis unit have aright to be free from a hostile and intimidatingdialysis environment, and it is the responsibilityof the health-care professionals, in conjunction

Box 2 Strategies for working with a difficult or

disruptive dialysis patient.

Patient-related strategies

Learn the patients story and seek to understand his

or her perspective.

Identify the patients goals for treatment.3

Share control of and responsibility for treatmentwith the patient:

Educate the patient so that he or she can make

informed decisions

Involve the patient in the treatment as much as

possible

Build on the patients strengths, such as

concern for his/her family

Negotiate a behavioral contract that specifies

what is to be done by the patient and the renal

team and when

Appoint a patient representative (friend/relative).9

Staff-related strategies

Approach the patient directly about their behavior.

Focus on the issue that started the disagreement.1

Use a nonjudgmental approach.1

Avoid communication spoilers such as criticizing

and name-calling a patient.8

Use reflective listening to show the patient that they

are being heard.

Detail the consequences of aberrant behavior in

terms that are comprehensible to the patient.

Prepare a behavior contract.

Prepare in advance to manage anger.

Be patient and persistent.

Do not tolerate verbal abuse.

Establish and publicize a patient grievance

procedure to patients and staff.

After effective resolution of a conflict, follow-up with

the patient to monitor progress and demonstrate to

the patient the commitment to resolve conflict.

Contact law enforcement officials when physical

abuse is threatened or occurs.

Contact the end-stage renal disease network if

disruptive or difficult behavior persists despite use

of the above strategies.

As a last resort, consider transferring the patient to

another facility or discharging him or her.

Obtain legal counsel before proceeding with aplan for discharge and do not discharge a patient

without notifying him or her in advance and

explaining future treatment options.

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with the administrative staff, to establish andmaintain such an environment.

CAUSES OF DIFFICULT OR DISRUPTIVE

BEHAVIOR

Finding out the cause of difficult or disrup-

tive behavior is important, in order to improvecommunication with the patient and to iden-tify the appropriate response.17 Difficult ordisruptive behavior can occur for any of thefollowing reasons.

The patient might lack the necessary skills,knowledge or resources to accomplish a task.8Limited mental capacity (e.g. because ofdementia) and limited financial resources canboth interfere with the patients ability to follow arenal diet or take medications as prescribed.A patient also might lack the transportation

necessary to purchase appropriate foods for arenal diet or to obtain medications.The patient might not understand what is

expected.8Improving a patients understandingof how dialysis works and why it is performedmight help the patient appreciate that he or sheneeds to receive three treatments a week andto remain on the dialysis machine for the fulllength of the prescribed treatment.

The patient might lack motivation.8Such apatient sees no reason for cooperating with staffor following medical advice. A good example isa patient who constantly complains that he orshe is on the dialysis machine for too long. Inthis case, providing an incentive to cooperatesuch as referral for renal transplant evaluationcould help.

Finally, the patient might have a psychologicalproblem. Patients with ESRD are faced withfear of death, loss of control over their lives, anddepression,10and can experience high levels ofanxiety,7all of which make it difficult to focuson medical advice. Dealing with patients feel-ings first is often helpful in this case.8 Somepatients have pre-existing psychiatric disorders

like major depression, bipolar disorder or schizo-phrenia, which can cause disruptive behavior.Appropriate treatment of these disorders mightimprove their behavior.10

STRATEGIES TO DEAL WITH DIFFICULT

OR DISRUPTIVE DIALYSIS PATIENTS

Successful strategies for working with difficultor disruptive dialysis patients help to create acalm environment in the dialysis unit1by useof a team approach. These strategies can be

divided into those that are patient-related andthose that are staff-related (Box 2). Education,training and policies3,8for dealing with difficultor disruptive patients should be available to alldialysis staff. Patients should be educated aboutthe policies for difficult or disruptive behavior

at the time of admission. Discharge of a diffi-cult or disruptive patient from a dialysis unitshould only be undertaken as a last resort afterthe other strategies presented in Box 2 have beenexhausted. The Medicare conditions for coverageof dialysis facilities require that dialysis patientsare provided with a written notice 30 days beforeinvoluntary discharge.18

CONCLUSIONS

Dialysis staff need to acknowledge that difficultand disruptive patients are a growing problem.

Because all patients deserve fair treatment, diffi-cult or disruptive dialysis patients should not beallowed to continually compromise the care ofother patients in the unit. The rights of diffi-cult or disruptive patients should be balancedwith those of other dialysis patients and staff.When there is real or threatened harm to otherpatients or staff, the balance should swing infavor of protecting these individuals. By exam-ining patients behaviors and the effects of thesebehaviors on others from an ethical perspective,it is possible to establish guidelines and policiesfor the management of challenging patientsin dialysis units. All dialysis units should havea policy for addressing the behavior of thesepatients, and all staff members should receivein-service training on the policy. Finally, use ofthe DPC training manual1is advised.

KEY POINTS

The number of difficult or disruptive dialysis

patients is increasing

The severity of difficult or disruptive behavior in

dialysis patients ranges from nonadherence to

physical abuse that endangers others

Ethical principles provide a framework for

making decisions about the management of

difficult or disruptive dialysis patients

Nonadherent behavior that is not harmful to

others does not justify involuntary patient

discharge from a dialysis unit

Abusive behavior requires balancing of the

disruptive patients needs with those of other

patients and staff

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Competing interestsThe authors declared no

competing interests.

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