This week's shooting of a cardiovascular surgeon in Boston, , again raised questions about family members of patients with adverse outcomes and why some do not merely become distraught but actively blame the medical staff.
We contacted a variety of clinicians and asked:
How can providers tell when a family member's grief is likely to turn into hostility toward the medical personnel?
What can providers do when they think they are being blamed for adverse outcomes, and what can providers do in addition to trying to improve communication with family members -- for example, offer grief counseling?
The participants this week are:
Robert C. Solomon, MD, FACEP, core faculty, emergency medicine residency, Allegheny General Hospital in Pittsburgh and assistant professor (adjunct), emergency medicine at Temple University School of Medicine in Philadelphia
Mary Jo Assi, DNP, RN, NEA-BC, FNP- BC, director, nursing practice and work environment, American Nurses Association in Silver Spring, Md.
Lewis Rosenbaum, MD, vice chief, medical services, department of internal medicine at Beaumont Hospital in Royal Oak, Mich.
Connie Barden, RN, MSN, CCRN-E, CCNS, chief clinical officer, American Association of Critical-Care Nurses (AACN) in Aliso Veijo, Calif.
Matthew F. Powers, MS, BSN, RN, MICP, CEN, president, Emergency Nurses Association in Des Plaines, Ill.
Robert L. Wergin, MD, FAAP, president, American Academy of Family Physicians and a primary care physician in Milford, Neb.
Know the Signs
: "Nonverbals are often the best indicators, along with tone and volume of voice. The person may appear tense or agitated. He may prefer to stand rather than accepting the offer of a chair. Other physical signs may be as subtle as posture or as obvious as repetitive clenching of fists. The healthcare professional's nonverbals, such as the offer of a handshake or a gentle touch on the shoulder, may be refused, resisted, or brushed aside. There may be escalation, in which the person goes from sitting to standing and pacing, or the voice goes from relatively calm and level to increasingly loud. There may be finger pointing or even poking or jabbing of the doctor or nurse with the extended index finger."
: "Prevention starts with the early recognition of verbal and nonverbal cues from patients or family members indicating stress and escalating anxiety such as rising tone and loudness of voice, swearing, clenching of fists, and tense body posture. Such signs should alert healthcare professionals to the potential for violent behavior by patients or family members, and the need for immediate intervention to defuse the situation."
: "Mentally ill family members may not have the capacity to understand the circumstances of their loved one's death, and their anger may escalate. Physicians and nurses must be on the lookout for clues to such aberrant behavior, including tangential or delusional thoughts, abusive language, sense of persecution by others (physicians and staff) and victimization. In occasional cases the hospital security must be engaged to assist in the staff's personal safety."
Have a Plan
Assi: "How a healthcare team member interacts with a highly stressed patient or family member is an important determinant to the outcome of the interaction. Avoiding a defensive attitude, taking the time to listen to the person's concerns, and expressing genuine willingness to work on the problem or issue together can de-escalate the situation quickly. Post-incident follow-up, such as a referral to a mental health specialist for further assessment, or to community support systems for grief counseling, may also help deter violent outbursts at a later time. It's important to note that even with de-escalation techniques, violence can still happen. A comprehensive workplace violence prevention program also includes environmental design and security measures (i.e., proper lighting, security personnel, cameras, metal detectors)."
: "Tragedies involving healthcare team members emphasize the need for hospitals to be prepared to respond quickly and effectively to threats of this nature. Establishment of a comprehensive plan for maintaining security in hospitals and units is a must. The best defense is education of all staff on how to respond in unexpected, life-threatening situations and ongoing dialogue between leaders and staff so that concerns are heard and acted upon. Collaboration by the entire team in addressing these safety concerns is the surest way to stay prepared for potential workplace violence."
: "Healthcare providers are at significant occupational risk for workplace violence and have the right to education and training related to the recognition, management, and mitigation of workplace violence. To that end, ENA has developed a workplace violence and for emergency nurses to: assess and differentiate individual and environmental risk factors for violence, select and explain appropriate individual and environmental responses to different levels of risk, and identify patterns of violence and implement prevention strategies. The material can really be applied to all healthcare providers who work in an emergency care setting."
Help With Grief
: "As family physicians, we have the privilege of forming long-term relationships with our patients. Because of that unique relationship, we're in a position to notice when a family member is angry, frustrated, struggling to cope, or might not be grieving in a healthy way. In situations like this, it's important to read those cues and acknowledge that the person is upset to provide empathy and validation. Allow the loved one to voice their feelings, and let them know you understand. Depending on the individual situation, you may offer them grief counseling or encourage them to seek guidance and support from a faith leader or other trained professional. When an apology is appropriate, it is the right and ethical thing to do and should be delivered with humility."
Solomon: "An offer of grief counseling is certainly appropriate, but it is not likely to be well received unless and until the healthcare professional has managed to calm the upset/angry person. If the frame of mind is still hostile and blaming, such an offer is likely to be viewed as an attempt to deflect or squelch the expressions of anger. Involving other family members or friends of the patient, if they are present at the hospital, could help if they are calm and rational. If no one else is present, an offer to bring them in may be appropriate: 'Is there anyone you'd like us to call to be here with you now?' This could even be a member of the clergy, as they are often very experienced with such stressful life events affecting members of their 'flock.'"
Powers: "The death of a patient is an event with emotional, cultural, procedural, and legal challenges. The enormity of the tragedy magnifies the challenges in simultaneously providing clinical care, holistic support for families, and care of the team delivering care while attending to significant operational, legal, ethical, and spiritual issues. The healthcare team should use a patient-centered, family-focused, and team-oriented approach when a patient dies, and is expected to provide personal, compassionate, and individualized support to families while respecting social, spiritual, and cultural diversity. In some circumstances, professional referrals may be appropriate and beneficial to both the grieving family and the healthcare team impacted by a significant loss."
Rosenbaum: "Grief is a part of life without which there would be no love. Sometimes, however, it is overwhelming. In these situations counseling with a professional often provides comfort and resolution. Most every hospital, hospice, and palliative care association provides such resources, and there are numerous private therapists who specialize in this care. Life and death are the grit of hospital life. Joy and grief are the aftermath. Holding patients and their families dear is the connection, and the best remedy for their grief."