Faculty Bibliography

PURPOSE: As mental health clinicians, we are committed to easing our patients' emotional suffering. As psycho- oncologists, our commitment is to ease suffering in people dealing with cancer. At times, patients' behaviors are abrasive, abusive or even aggressive - out of the norm of what we commonly see, such behavior may be more common in community psychiatric or forensic settings. This presentation discusses a situation when a patient's actions acted to repel clinicians; despite staff attempts to be sympathetic and professional to someone with life threatening cancer, the patient managed to alienate staff and potentially sabotage her ongoing treatment. METHODS: This account describes the case of a woman who presented to the outpatient cancer center of an academic medical center s/p 2/6 cycles of chemotherapy for a potentially curable lymphoma. She had been "terminated"/forcibly ejected from at least 2 prior medical centers and refused treatment elsewhere. She presented for care ten days late for her third cycle. Demanding with support staff, within minutes of meeting the oncologist, psychiatry were called to "help with this emergency". Lengthy discussions with team members regarding appropriateness to deliver, or refuse, care to this patient ensued. A behavioral contract was completed prior to initiating chemotherapy. RESULTS: This case required close coordination between oncology, nursing, social work, psychiatry, administration and risk management. Considerable time was spent in making a decision around provision of safe care compatible with ethical guidelines. Techniques utilized to maintain team cohesion, tolerate patient and staff affect, and to protect patients and staff alike are discussed. Despite extensive team efforts and a behavioral contract, the patient's behavior continued to escalate. CONCLUSIONS: Patients who are abusive to staff are challenging to handle. A concomitant psychiatric diagnosis can make things more challenging still. Behavioral contracts, while helpful in theory, have limited utility since they have "no teeth"; despite best efforts to be empathic, professional and "focus on the patient", the life-threatening nature of cancer makes it difficult to impose negative consequences i.e. refuse to treat patients who behave in an unacceptable manner, (particularly when it is due to psychiatric illness). Such taxing cases trigger intense feeling in staff and without sufficient team cohesion and institutional recognition of the burden, risk burnout. Research Implications: Much has been written in mental health literature about "countertransference" and its role in patient care; there has been some writing about countertransference particular to psycho-oncology where we are, by definition, dealing with potentially life-threatening illness. However, little has been written about how to manage such "dirty" cases where a patient's behavior or psychiatric illness intersects with a treatable, life threatening illness. The fact that the patient has a potentially curable medical illness can constrain staff in their ability to set limits and consequently safely deliver, or refuse to deliver, care; this is an area ripe for further research. Clinical Implications: Psycho-oncology can be an intensely gratifying field given a perspective of easing patients' feelings of isolation or their emotional suffering. However, this outlook can be challenged by "difficult" cases where it can be hard to feel empathic. Sharing our experience and the means by which teams handle such challenges can serve to help others in similar situations; in addition, it enables all individuals involved in such cases to feel better prepared for the next such case. It is hoped that it will prevent feelings of isolation in team members and avoid feelings of burnout