A 62-year-old man comes to the office due to weight loss, persistent cough, hemoptysis, and dyspnea, after having cancelled several previous appointments. The patient has been under stress lately as he is going through a divorce, and he recently had to postpone his retirement plans when several business deals fell through. He has a history of substance abuse, with episodes of residential treatment for cocaine and alcohol abuse. He no longer uses cocaine but continues to use alcohol daily "to relax." During the visit, a chest x-ray shows a suspicious mediastinal mass. The physician explains the need for a chest CT scan and tissue biopsy. The patient says, "My whole life is going to crap. I suppose you're going to tell me to stop smoking. What do you know? You doctors are all the same. Do this, don't do that; meanwhile, you go home in your fancy cars to your fancy homes. Well, you know what? I'm going to keep smoking and get drunk as hell tonight!" Which of the following is the most appropriate response to the patient?

Question

A 62-year-old man comes to the office due to weight loss, persistent cough, hemoptysis, and dyspnea, after having cancelled several previous appointments.  The patient has been under stress lately as he is going through a divorce, and he recently had to postpone his retirement plans when several business deals fell through.  He has a history of substance abuse, with episodes of residential treatment for cocaine and alcohol abuse.  He no longer uses cocaine but continues to use alcohol daily "to relax."  During the visit, a chest x-ray shows a suspicious mediastinal mass.  The physician explains the need for a chest CT scan and tissue biopsy.  The patient says, "My whole life is going to crap.  I suppose you're going to tell me to stop smoking.  What do you know?  You doctors are all the same.  Do this, don't do that; meanwhile, you go home in your fancy cars to your fancy homes.  Well, you know what?  I'm going to keep smoking and get drunk as hell tonight!"  Which of the following is the most appropriate response to the patient?

Quizplus · Accepted Answer

Explanation: Although it is likely that this patient's suspected lung cancer diagnosis and recent losses (ie, divorce and financial problems) are contributing to his distress and verbally abusive behavior, the specific cause of his anger is unclear. Although it may be challenging, it is the physician's responsibility to be nondefensive, defuse the patient's anger, and attempt to preserve the physician-patient relationship. The best approach is to acknowledge the patient's anger and clearly express empathy for his situation. This can deescalate his anger, enabling him to calm down without feeling humiliated and join the physician in developing a collaborative treatment plan. The physician must use clinical judgment to determine if the patient's anger is escalating to the point where there are concerns for safety. Signs of impending violence include increased motor restlessness, pacing, loud speech, clenched fists, pounding walls, or throwing objects. In these circumstances, the physician should set a limit by ending the visit, politely exiting the room, and calling security. (Choice A) This statement acknowledges the patient's anger but is defensive and nonempathic. (Choice B) Pointing out the inappropriateness of the patient's behavior is likely to be perceived as condescending and judgmental, leading to further deterioration of the physician-patient relationship. The first step should be defusing the patient's anger and attempting to preserve the relationship. (Choice C) The first part of this statement shows empathy, but counseling about smoking and drinking at this time would likely anger the patient further. (Choice E) This statement fails to acknowledge the patient's anger. Educational objective: Encounters with angry, verbally abusive patients are best managed by acknowledging the anger and attempting to preserve the physician-patient relationship with a nondefensive, empathic approach. References: Defusing the angry patient: 25 tips. (http://www.ncbi.nlm.nih.gov/pubmed/21243886) Possibly impossible patients: management of difficult behavior in oncology outpatients. (http://www.ncbi.nlm.nih.gov/pubmed/22043189)

A 62-Year-Old Man Comes to the Office Due to Weight