Healing responses may include turning to music, art, religion, literature, nature, humor, or psychotherapy for solace and understanding. Spiritual questions of purpose and meaning in life become more immediate in the face of impending death.

Under the Medicare Hospice Benefit, hospices provide bereavement support for at least a year to families of patients they have served. They also provide bereavement services to partners and close friends. Often, hospices provide this support to people in their community even if the death did not occur with hospice care.

Physicians and nurses may want to call in clergy and social workers; each may have something to offer a family that is trying to integrate the shock and loss.

If patients have lost the capacity to express their wishes and family members are in conflict about a certain plan, it is best to focus on what the patient would have wanted, applying the ethical principle of substituted judgment.

The clinician needs to communicate clearly with the family members regarding plans for care, prognosis, complications, and who will make decisions should the patient be unable.

The search for love, a connection to others, and a sense of meaning are essential in helping patients through the dying process.

CASE ILLUSTRATION 9 A 64-year-old veterinarian, Richard, develops headaches so severe that he can no longer carry on his surgical practice.

Guidelines for assisted suicide have been published, and clinicians confronted with a reasonable request to end life should refer to these, as well as to colleagues experienced in palliative care, for help. In almost all cases, legally permissible and clinically preferable alternatives can be found.

A patient’s request to hasten death should be explored in detail. At first, it should be considered a cry for help. It may represent the wish to escape from depression, anxiety, uncontrolled physical pain, shame of dependency, and other psychosocial issues.

CASE ILLUSTRATION 8 Sara, a bedridden 84-year-old woman with end-stage congestive heart failure, is seen on rounds.

In assisted suicide, the physician provides the means (such as a prescription for barbiturates) at the request of the patient, but the patient must eventually take (or not take) the potentially lethal medication by his or her own hand.

Voluntary active euthanasia is the act of intentionally intervening to cause the patient’s death, at the explicit request of, and with the full informed consent of, the competent patient.

Table 42-2.Last resort interventions: definitions.

Withdrawing life-sustaining but burdensome treatments, even though the withdrawal leads to death, is also an accepted part of practice based on the patient’s right to bodily integrity.

CASE ILLUSTRATION 7 Marvin is a 63-year-old man with amyotrophic lateral sclerosis who has been on a respirator at home for one year.

Patients who recover from delirium and coma sometimes report experiences that range from nightmarish, terrifying visions, on the one hand, to very pleasant out-of-body travel or visions of light and angelic beings on the other. Some may not be able to remember anything about the experience. Occasionally, the disorientation becomes profound and the sense of the world is lost. ++

CASE ILLUSTRATION 6 Caleb, a 101-year-old rugged dairy farmer, has become partly deaf and then blind in the last 5 years of his life but remains alert and communicative.

Patients have the right to forgo therapies such as intravenous fluids, nasogastric feeding, and supplemental oxygen, among others. Documentation of these choices is vital if the patient does not wish to undergo treatments and can be done on the MOLST form.

The notion that being resuscitated from cardiopulmonary arrest will not add appreciably to the quality and/or quantity of life is an open acknowledgment that death might be near—and that reversing the dying process is not within the power of medicine.

The “do-not-resuscitate” (DNR) order refers to the withholding of CPR, specifically closed-chest cardiac massage, defibrillation, and artificially supplied respiratory support. For most patients with a terminal disease, CPR is ineffective, and its harshness makes it a cruel, expensive, technological death ritual. Many studies have shown that CPR provides no increase in out-of-hospital survival for patients with progressive multisystem disease, particularly patients with advanced cancers and renal failure.

Advance directives are formal documents that direct health care decisions should patients lose the capacity to speak for themselves in the future.

There are two types of advance directives: living wills and health care proxies (also called durable powers of attorney). ++

Invasive interventions that exceed the usual boundaries of hospice care but that extend meaningful life and improve quality of life are sometimes appropriate even within a hospice approach, as long as the patient consents. Remaining flexible in the face of changing, difficult situations and allowing the patient’s goals to guide the treatment as much as possible permit the clinician to hope along with the patient for a death with as little meaningless suffering as possible.

CASE ILLUSTRATION 5 Rhea, a 64-year-old woman with metastatic breast cancer, is on high-dose long-acting morphine because of bone pain.

CASE ILLUSTRATION 4 Max, a 63-year-old, recently retired, and previously healthy man, develops abdominal pain and is found to have widely metastasized colon cancer.

Providing ranges of survival times and allowing for outliers on either end is better than predicting an exact amount of time. (“The average person with your illness will live two to six months. It could be longer, and we will try to make that happen, but it could also be shorter, so you may want to make sure everything is prepared just in case things don’t go as we hope.”)

CASE ILLUSTRATION 3 At 68 years old, Albert has severe end-stage emphysema from years of smoking, severe mitral regurgitation, congestive heart failure, cardiac arrhythmias, and alcoholism.

For some, dying may be a time for personal growth, reflection, and meaning, but for others, personal factors and emotional reactions block an acceptance of death.

CASE ILLUSTRATION 2 Carlos, a 70-year-old man, has been diagnosed with advanced hepatocellular carcinoma.

Progressive declines initially may be treated as another form of bad news, but they also potentially provide the opportunity for enhanced meaning and control in the dying process.

Table 42-1.End-of-life issues to be discussed with patients.

This sadness, which may be a way of preparing for death, has been called preparatory or anticipatory grief.

Hospice programs provide comprehensive care to dying patients, with a multidisciplinary team of nurses, physicians, social workers, clergy, and volunteers. These programs, which accept only patients who are more likely than not to die in the next 6 months and are willing to forgo disease-directed therapies and hospitalizations, help patients and their families live as fully as possible by providing quality palliative care.

The advantage of hospice programs is the expertise brought to techniques of palliative care by the multidisciplinary staff, as well as the added support for patient and family at home, including payment for palliative medications and medical equipment.

Unlike Medicare-sponsored hospice programs, palliative care does not require patients to give up on aggressive treatment of their underlying disease, to accept a prognosis of less than 6 months, or to accept palliation as the central goal of therapy. Thus, it allows “hospice-like” treatments to be made available to those seriously ill patients who want to continue some or all disease-directed treatments.

This “both/and” approach has been one of the most important conceptual breakthroughs for palliative care, for it allows quality-of-life issues to be addressed for all seriously ill patients, not just those who are referred to hospice.

CASE ILLUSTRATION 1 Ella, a 71-year-old woman

Figure 42-1. The place of palliative care in the course of illness.

Enhancing the quality of life for those afflicted with serious chronic illness is the cornerstone of the rapidly developing specialty of palliative care.

Patients with undetected trauma histories are often seen as “difficult” or “hostile,” frequently are late or miss appointments, are often in crisis, have poor self-care, and chronic pain. Such patients also may be labeled as “noncompliant,” with seemingly intractable health behavior problems.

When trauma-focused psychotherapy is not available, national guidelines recommend pharmacotherapy, in particular sertraline, paroxetine, fluoxetine, or venlafaxine as first-line monotherapies.

In addition to the misuse of substances, another common comorbidity of PTSD is insomnia.

Chronic pain, smoking, and obesity are also common comorbidities with PTSD.

Other primary prevention strategies for primary care practices include support for new parents, support for home visiting programs, and universal preschool options, and firearm access reduction.

In addition to risk reduction strategies, characteristics that promote resilience in survivors such as self-esteem, trust, humor, internal locus of control, secure attachments, and social relationships, as well as a personal sense of safety, religious affiliation, strong adult role models, and use of existing resources can be reinforced by primary care clinicians.

Table 41-3.First steps to trauma-informed primary care.

Unlike recent trauma, disclosures of past trauma do not require an immediate intervention. Rather, clinicians can express empathy (“I’m so sorry that happened to you. You didn’t deserve that”) and provide information about the availability of services to help cope with and heal from past trauma (“I am available to talk more with you about that.

An appropriate response to recent IPV affirms that the patient does not deserve to be treated in this way and expresses concern for his/her safety. It also typically also includes a “warm handoff” to a domestic violence agency by telephone and/or to an onsite psychosocial team member who can construct a safety plan; lethality assessment, referrals for safe housing, legal, police, and other community resources; individual and/or group therapy; and peer support.

Figure 41-1. Trauma-informed health care.

PTSD symptoms are grouped into four distinct clusters: re-experiencing the trauma (memories, nightmares, flashbacks), avoidance (emotional/cognitive vs. situational), negative changes in thinking/mood (not remembering aspects of the trauma, changes in beliefs about self/others/the world, self/other-oriented blame, persistent negative emotions, anhedonia, isolation, difficulty experiencing positive emotions), and arousal (sleep disturbances, irritability/anger outbursts, exaggerated startle, hypervigilance, attentional disruption, self-destructive behavior).

When referrals are not available for your patients, primary care clinicians can be reasonably confident in their diagnosis of posttraumatic symptomatology and need for trauma-focused treatment referral when a patient:

A score of 3 or more on the PC-PTSD-5 confers a high likelihood of trauma-related psychological distress and/or PTSD.

Table 41-2.The Primary Care PTSD Screen for DSM-5.

The most common forms of posttraumatic psychopathology include acute stress disorder (ASD) and posttraumatic stress disorder (PTSD).

Patients with trauma exposure commonly present to primary care and other settings with seemingly unrelated acute or chronic physical and mental health conditions at much higher rates than patients without trauma exposure.

Table 41-1.Four steps to inquire about trauma.

Techniques described by Dr. Leigh Kimberg as the “Four C’s” can help prepare you to inquire about, and respond to, recent or past trauma:

Examples of patient education include: posters and flyers in the waiting area, brief informational pamphlets given to patients when taking their vital signs, and invite conversations as part of routine practice and/or when trauma-related conditions are discussed.

Demographic factors such as female gender, age, socioeconomic status, and African American race often are thought of as nonmodifiable risk factors, but it is increasingly clear that societal response to race, gender, or age, and the resultant chronic stress, may create the actual risk in these populations.

More than one-third of U.S. women experience stalking, physical violence, and/or rape from an intimate partner during their lifetimes. One in five men experiences sexual violence in their lifetimes.

Individuals who reported four or more ACE categories had 2 times the rates of lung and liver disease, 3 times the rate of depression, 3 times the rate of alcoholism, 11 times the rate of intravenous drug use, and 14 times the rate of attempting suicide than those who reported ACE scores of 0.

The study revealed a strong dose–response relationship between childhood trauma and adult heart, lung, and liver disease; depression; substance abuse; obesity; diabetes; sexually transmitted infection risk; and intimate partner violence (IPV).

Notably, 25% of women and 16% of men reported having experienced childhood sexual abuse

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma as “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects.”

f the communication of serious news does not go well, misunderstandings can ensue, causing increased conflict between providers and patients and families, which has been shown to lead to poor quality decision making.

Table 3-2.Ways to explore cultural beliefs in discussing bad news

In some cultures, disclosure of truth is believed to cause bad outcomes, and nondisclosure can be protective and benevolent.

Hope often initially focuses on outcomes that are strongly desired and reflect individuals’ varying beliefs, values, and sense of possibility.

Physicians who focus the relationship on hope alone may feel as if they are being dishonest with the patient and may withdraw from the relationship as the patient becomes sicker.

These two strategies, hoping for the best and preparing for the worst, need not be mutually exclusive. Hoping, while simultaneously preparing, minimizes the weakness of each strategy on its own.

Specific hope is the state of desiring a specific possible event or future state of affairs, called the hope object.

How much stress a physician experiences prior to sharing the news is exacerbated when the physician is inexperienced, when the patient is young, and when there are limited prospects for successful treatment. Physicians may feel uncertain about how the patient will

There may be a reluctance to deliver serious news, known as the “mum effect,” that may result in the physician holding onto the serious news for a prolonged time prior to contacting the patient.

Providers must be aware of their personal beliefs about illness, death, and dying prior to sitting down with the patient, to ensure that they are not inadvertently pressuring patients to respond in a certain way.

This model of decision making is the norm in Western culture, but not in all cultures.

Research and anecdotal information remind us that many patients do not often remember most of the initial serious news discussion once the diagnosis is spoken.

Present the possible treatment options in small bits and elicit patients’ values and preferences as it relates to the possible treatment options.

Doctors consistently overestimate survival in terminally ill patients, especially those who have a short life expectancy.

Step 6, the final step of the SPIKES protocol (Set goals)

A good surrogate expression for “I’m sorry” is an “I wish” statement. “I wish I had better news for you” allows the physician to walk in the patient’s shoes while acknowledging that the news is unlikely to change.

When giving serious news to a patient or family, generally avoid apologizing unless you have clearly made a mistake that you are ready to acknowledge.

If a physician is feeling anxious while anticipating a response from a patient after having given serious news, this may represent the physician’s own response and not necessarily a guide to how the patient is feeling (countertransference).

However, if an empathic response is done without sincerity or when a patient is not receptive, it can end up being harmful to a therapeutic relationship.

An approach to responding to patient emotion.

Sometimes patients may have to deal with strong negative emotions (see next section) after hearing serious news before they are able to see hope. But even in circumstances where there is no further effective treatment, one can potentially be hopeful for a good quality of life moving forward or for other important personal or family outcomes.

Step 1 of the six-step SPIKES protocol (Set up the interview)

Step 5 in the SPIKES protocol (Emotions)

A good rule of thumb along the lines of “ask, tell, ask” is to give at most three pieces of information at a time before checking for understanding.

Excessive bluntness must be avoided (“There is nothing we can do to treat this cancer”) to keep patients feeling engaged in the conversation and to avoid inciting a feeling of isolation and anger—but one should try to gauge what and how much additional information is given by soliciting what additional questions the patient and family may have.

Step 2 of the SPIKES protocol (Perception)

Step 4 (Knowledge)

Step 3 of the protocol (Invitation)

Most patients indicate during research studies that they want as much information as possible about their illness, though they may not express their full desire to providers (and they may not retain the details of what has been shared if they have a strong emotional response to the news).

Ask what the patient and family know and what they want to know. Some patients may choose less-than-full disclosure in regard to their medical conditions, and you cannot know without asking.

In addition to the optimal physical setting, physicians should prepare for the conversation by finding out the medical information necessary to answer any anticipated questions. Talking to consultants about specific diagnoses, test results and treatment options in advance will help when formulating a plan with the patient.

The space chosen for this purpose should be private, quiet, comfortable, and convenient for everyone involved. Identify the key participants that should be present, including family or friends who the patient identifies as being close supports, as well as practical additions to the team, such as nurses, interpreters, social workers, and consultants who know the patient well.

Table 3-1.The SPIKES protocol for delivering bad news.

Patient-centered communication is an approach in which attention is placed on using verbal and nonverbal behaviors to establish partnerships with patients.

Patients will often feel encouraged to participate in difficult decision making when they are connecting with their physician, which can result in higher quality medical decision making.

In one survey, only 5% of oncologists said that they learned to give serious news through a formal teaching program; most had either learned by sitting in on other clinicians giving such information or had no formal teaching at all.

Prior literature in this area describes these conversations as “breaking bad news.” However, in a qualitative study from 2011 on this topic, patients did not like clinicians judging what was considered “bad” news, and valued framing the news as something to work through with the provider, rather than just labeling it as “bad.”

Bad news is defined in the literature as any information likely to alter drastically a patient’s view of his or her future.

In 1990, the data showed a dramatic upward trend in disclosure with 97% of surveyed physicians disclosing an unfavorable diagnosis to their patients.

In 1961, 90% of physicians preferred not to share a cancer diagnosis with their patients.

In 1847, when the American Medical Association (AMA) published their First Code of Medical Ethics, they agreed, stating that “The life of a sick person can be shortened not only by the acts, but also by the words or manner of a physician. It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things which have a tendency to discourage the patient and depress his spirits.”

In Decorum, Hippocrates wrote, “… conceal most things from the patient while you are attending him. Give orders with cheerfulness and serenity, turning attention away from what is being done to him [because] a forecast of what is to come can cause a turn for the worse.”

Clinicians should attempt to understand the role that the symptoms play in the patient’s family and social systems to gain insight into why the symptoms persist despite the lack of a somatic etiology.

Data on the efficacy of using medications to treat somatic symptom disorders is limited; to date there are few randomized, controlled studies. However, there have been several small, open studies demonstrating the effectiveness of selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, and escitalopram; serotonin norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine; and other antidepressants classified separately (mirtazapine) in reducing somatic complaints, depressive symptoms, and improving overall assessment of health.

Table 29-3.Management of somatic symptom disorder.

Unfortunately, many patients with somatic symptom disorders may not be enthusiastic about exploring unconscious conflicts. In general, psychodynamic psychotherapy is a longer-term, time-intensive approach that requires a referral to a specialist and a significant commitment from the patient.

Cognitive behavioral therapy (CBT) has been studied as a means of addressing medically unexplained somatic symptoms. This treatment is based on the theory that incorrect beliefs about bodily functioning underlie these symptoms or produce much of the dysfunction.

Psychodynamic psychotherapy is based on the assumption that the individual is experiencing internal emotional conflicts and that the associated emotions cannot be identified or expressed.

Further, a consultation model in which the patient is asked to see the mental health provider for one or a few visits to “advise and help the primary care provider do a better job” is often more acceptable to patients than a referral for ongoing treatment.

Another method for treating patients with somatic symptom disorders in the primary care setting is for practitioners to teach patients to reattribute and relate physical symptoms to psychosocial problems.

A novel treatment for somatic symptom disorders involves the use of a “written self-disclosure protocol.”

Moreover, patients learn that they will receive this care and attention even without new symptoms or exacerbations of existing symptoms. The clinician may also ask patients when they want to return for the next visit. This provides them with a sense of control, and over time many patients will suggest lengthening the interval between appointments.

The practitioner should never challenge the reality of the patient’s physical symptoms. Somatic symptom disorder is an unconscious process, and therefore the somatic complaints are very real to the patient.

Medical providers should avoid trying to convince the patient that the symptoms are psychological in origin. They should also avoid the use of psychological labels (e.g., depression, anxiety).

Another management suggestion is to have the provider evaluate the patient in an appropriate manner to rule out somatic causes of their symptoms.

*Experts suggest that the phrase “Is there something else?” is preferred over “Is there anything else?”

Instruments such as the self-administered Patient Health Questionnaire (PHQ), which are designed for use in primary care settings, can help the provider diagnose somatic symptom disorders as well as depression, anxiety, eating disorders, and substance use disorder.

The clinical interview can be helpful in establishing the presence of psychiatric illness as well as in communicating to the patient that the clinician is taking an active interest in the individual’s life.

As with all of medicine, the first step in evaluating the patient with multiple somatic complaints is a detailed and thorough history of the presenting problem.

Factitious disorder is included in the category of somatic symptom and related disorders. It is diagnosed when the clinician determines that the symptoms are consciously or voluntarily induced or exaggerated. However, in these individuals there is no discernible external incentive, such as financial compensation, to produce the symptoms.

Table 29-2.Abnormal illness-affirming states

Patients with psychotic disorders, such as schizophrenia, may also present with multiple somatic complaints. In contrast to the concerns in the somatic symptom disorders, psychotic symptoms tend to be bizarre or completely irrational (e.g., “My insides are rotting” or “I have pain from the dinosaur eggs in my stomach”).

Whereas the somatic symptoms of the somatic symptom and related disorders tend to be chronic, the physical complaints in depression exist only in the presence of the mood symptoms.

Several psychiatric disorders have been associated with somatic symptoms and should be considered when evaluating a patient who has physical complaints.

In evaluating patients, it is important to remember that the onset of multiple physical symptoms late in life is almost always due to a general medical condition; somatic symptom disorders generally start decades earlier.

Research has consistently demonstrated that individuals with somatic symptom disorders have worse health outcomes, physical functioning, and psychological well-being than those patients who do not manifest these symptoms.

One study estimated that patients with somatic symptom disorders generate medical costs nine times those of the average medical patient.

Although studies have demonstrated there is no systematic pattern of cultures which are more or less likely to have somatic symptom disorders, it appears that patients who lack an ongoing relationship with a stable provider are more likely to have a greater number of somatic symptoms.

Research has also shown that 50–80% of patients who have an anxiety or depressive disorder initially present to health care providers with physical symptoms

his view begins with the clinician abandoning the either–or categories of “physical” and “psychological.” This dichotomous framework leads to interactions in which patients feel that they and their symptoms are being discounted by the clinician and conclude, “The doctor’s saying it’s all in my head.”

Although the western medical model focuses on the biological aspects of disease, it often ignores the psychological and sociocultural facets of the patient’s experience. In addition, this model, often very effective for understanding and treating acute disease processes, may fail to explain much of the complexity of chronic illness.

Using the biopsychosocial model, illness can be understood as occurring along a spectrum with disorders characterized by predominantly somatic problems at one end and disorders with predominantly psychological or social manifestations at the other (see Chapter 36).

Figure 29-1. Symptom amplification.

The clinician’s task in these meetings is to correctly recognize which of the patient’s somatic complaints represent cultural idioms of emotional distress.

According to the sociocultural perspective, individuals learn to express disease and distress in culturally sanctioned ways. In any culture, the expression of certain bodily symptoms and illness behaviors are encouraged whereas others are discouraged.

CASE ILLUSTRATION 4

The processing of bodily information gradually becomes colored by the belief that the person has a disease, and this can result in the affected individual embracing the sick role.

According to cognitive behavioral theorists, symptoms of somatic symptom disorders arise from incorrect beliefs about bodily sensations, for example, the belief that mild gastroesophageal reflux (or panic symptoms) represents myocardial ischemia.

CASE ILLUSTRATION 3

A four-category model has been proposed, which describes four different types of attachment: secure, preoccupied, dismissive, and fearful. In particular, research examining the role of attachment style and its link to somatic symptom disorder and subsequent health care utilization has found that patients with preoccupied attachment (where the individual tends to idealize others, is less self-reliant and needs more reassurance) and fearful attachment (where the individual may be less trusting of others as well as less self-reliant) are more likely to be high in somatic symptom reporting and are higher users of medical resources.

Additional research has examined the inability of individuals with somatic symptoms to habituate to novel stimuli.

It is hypothesized that abuse places individuals at risk for the types of internal conflicts that result in somatic symptom disorders. For example, women who have suffered sexual abuse in childhood have increased rates of chronic pelvic pain when compared with those without a history of abuse.

CASE ILLUSTRATION 2

Medically unexplained syndromes have persisted as clinical problems for practitioners. Patients often present with many symptoms that are not associated with abnormalities demonstrable by physical examination or laboratory or radiological studies. The symptoms are often clustered together as syndromes with a variety of proposed etiologies, including environmental exposures, infections (e.g., chronic Lyme (Borrelia burgdorferi) disease, Candida, Epstein–Barr virus), or multiple chemical sensitivity.

Table 29-1.Somatic symptom and related disorders.

But if they lie for some form of financial or material gain, this is considered “malingering”

In other patients, the process may be more persistent, and the symptoms may be disabling. In yet others, somatic symptoms may be a more culturally appropriate expression of other psychiatric disorders like depression or generalized anxiety.

The term somatic symptom disorder (SSD) as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is broadly characterized by somatic (physical) symptoms that are either very distressing or result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings, and behaviors regarding those symptoms.

CASE ILLUSTRATION 1

College students with untreated ADHD often report that despite rereading material multiple times, they cannot remember it.

Fostering the therapeutic alliance requires developing trust, conveying empathy, and collaborating about treatment goals. Depending on the skills, attitudes, and orientation of clinicians and the systems in which they work, the clinical encounter can increase social distance and exacerbate the effects of vulnerability on health, or it can lead to productive engagement with patients to mitigate or even eliminate the effects of vulnerability on health.

Health care systems wishing to recruit and retain clinicians caring for vulnerable populations should provide opportunities for clinicians to develop these intrapersonal and interpersonal skills and enhance the clinical resources that allow clinicians to feel successful in this work.

Clinicians who have been able to sustain therapeutic relationships with vulnerable patients and maintain fulfilling careers in the care of vulnerable populations tend to

Although clinicians in underserved clinical settings report serving higher proportions of medically and psychosocially complex patients, they are more likely to report a chaotic work environment and less likely to feel in control.

Fourth, after identifying vulnerability, the clinician should not forget the important step of exploring with the patient, in a supportive and nonjudgmental manner, how the vulnerability may be affecting health and care and how to mitigate these effects.

Third, in the process of assessment, the clinician should be sensitive to the concerns of patients with respect to shame and stigma.

For example, in countries with universal health care coverage, lack of insurance simply does not contribute to vulnerability.

Table 18-3.Resilience factors.

The first is that in the pursuit of identifying vulnerability, the clinician should be reminded of the importance of simultaneously identifying and acknowledging an individual’s strengths, resilience, and range of resources, such as one’s belief in a higher power or support from a religious community; or the love and support provided by a spouse, friend, or pet.

Table 18-2.Common pitfalls in assessing for vulnerability.

hen faced with a patient who is doing poorly from a clinical standpoint, many clinicians do not reflect on the psychosocial factors that may be influencing the patient’s course. They may simply throw up their arms and attribute a patient’s clinical decline to his or her social milieu in a global or at times derogatory fashion, referring to such a patient as “nonadherent,” a “difficult patient,” or a “social nightmare,” without digging deeper.

Table 18-1.Generating a differential diagnosis of psychosocial vulnerabilities.

While there are many reasons for the observed variation in quality and health outcomes, one of the most important and frequently least appreciated factors is the patient’s social context

Eliciting the patient’s story can also improve patient trust, satisfaction, and adherence. It enriches and brings meaning to interactions and allows providers to be more effective and engaged.

Patient’s perspectives—a complex mixture of very personal beliefs, values, and assumptions reflecting multiple influences—can determine how they develop a relationship with their clinician, and whether they feel understood and respected or misunderstood and discounted. Clinicians, in turn, have their own individual perspectives on health and illness, and ascribe specific meaning to their role as healers

Personal concepts of health determine what preventive and self-care behaviors are considered appropriate, which symptoms seem worrisome, and when to seek help from health care professionals.

The same factors that influence how people think about health and illness also impact other aspects of their lives, and eliciting information about these influences can uncover perspectives important to health care.

We should also clarify our own boundaries; it is not uncommon for a relationship between a clinician and a patient to evolve into one of unhealthy dependence or unrealistic expectations.

However, if clinicians consciously strive to transmit a sense of trust, caring, and respect, along with a desire to enter into true partnership, they increase the likelihood of forming productive relationships with patients. Some guidelines to consider in this process include the following:

Significant proportions of people from African American, LatinX, and Asian communities and those with lower educational attainment have reported that they were treated with disrespect, were treated unfairly, or received worse care because of their position in society.

Caring—Patients who are poor and/or have historically faced racism and discrimination frequently receive care in teaching hospitals and community health centers with high provider turnover.

What Is the Therapeutic Alliance? ++ In the field of medicine, a therapeutic alliance exists when the patient and provider develop mutual trusting, caring, and respectful bonds that allow collaboration in care and treatment.

The clinician has the ability to collaborate on treatment plans and to facilitate entry into the various health and social systems that can help address vulnerabilities. The therapeutic alliance can help patients feel assured that clinicians will not abuse the disclosure of information (e.g., leading to rejection or legal action) but will help them access resources critical for their health.

CASE ILLUSTRATION 2

Key dimensions of the therapeutic alliance include: ++ Mutual trust—Patients need to trust in their clinicians’ integrity and competence, and clinicians need to trust that patients enter the relationship trying to do their best. Empathy—Demonstrating empathy, or recognizing and understanding the beliefs and emotions of another without injecting one’s own, allows the clinician to connect emotionally with the patient without pity or overidentification. Respect—Expressing respect for patients and treating them with dignity are important and require creating a context in which communication can occur as equals. Collaboration—Collaboration requires a meaningful partnership in which the clinician and patient perceive that they are working together toward a common goal and committed to resolving conflicts that inevitably emerge about treatment goals.

The third mechanism, also an indirect one, is mediated entirely through the therapeutic alliance. In this path, the vulnerability affects components of the relationship or therapeutic alliance with the provider (such as open disclosure, mutual trust, caring, and engagement), thereby limiting the benefits of a collaborative relationship on care.

A second path is an indirect one, where the vulnerability attenuates the benefits of medical treatment on coexisting medical conditions; that is, the vulnerability presents a barrier to optimal acute, chronic, and/or preventive care, thereby accelerating disease course.

The first path is a direct one, a situation in which the vulnerability in and of itself leads to poor health.

Figure 18-1. Creating a context for effective intervention in the clinical care of vulnerable patients.

Unfortunately, vulnerable patients experience a triple jeopardy when it comes to health care: they are more likely to be ill; more likely to have difficulty accessing care, and when they do, the care they receive is more likely to be suboptimal.

Social characteristics—living in poverty, having a low level of education and limited literacy skills, being from a community that has experienced racism and discrimination, having no health insurance, speaking little English, among other factors—make individuals vulnerable to contracting illness and to facing overwhelming obstacles in the care of that illness.

CASE ILLUSTRATION 1

nderused skills such as soliciting the patient’s attribution for a problem, offering praise and support, listening carefully to the patient’s description of a problem, and explicitly confronting problematic or confusing behavior inform the patient that a serious attempt is underway to understand and successfully manage the patient’s concerns.

Indications for referral include inability to make a diagnosis, an objective assessment that the patient is not benefiting from evaluation or treatment, or the clinician’s feeling of being threatened or in danger.

What did you say or do that contributed to moving beyond the difficulty? What did the patient contribute to changing your relationship in a positive direction? What was it about the environment or circumstances of your encounter that improved the situation or your relationship? What changes did you make in your internal appraisal or perception of this patient that made a difference? What will you do differently the next time?

CASE ILLUSTRATION 4 (CONTD.)

Descriptions of behavior that hit home can provoke emotional responses in patients, but penetrating long-held psychological defenses can spur growth.

Over time, patients learn to respond to the support offered and begin to take a more active role in their care. Of course, there is always the risk that a passive–aggressive individual attempting to control the relationship will choose to seek another clinician who can be more easily manipulated.

The next step is to ask what the patient thinks would be helpful in solving the problem.

“Am I encouraging patients to take a more active role in their care?” and “Am I giving patients the chance to say why they’re not using the treatments I thought we agreed on?”

Finally, the patient’s previous experiences with clinicians may have been so hierarchical and paternalistic that the thought of disagreeing or negotiating a position does not come to mind, even when the suggested approach is not acceptable.

When problems are being discussed, this type of patient’s nonverbal behavior is usually engaged and active: leaning forward, bright affect, and dynamic gestures. As recommendations for evaluation and treatment are made, however, the patient typically becomes withdrawn, eye contact diminishes, and language becomes significantly less animated. Verbally, during the discussion of evaluation and treatment, the patient becomes quiet, volunteers little, and characteristically offers no solutions to problems. In fact, as the clinician makes recommendations, the patient often responds with the classic, “I’d like to do that but … .”

CASE ILLUSTRATION 4

Summary ++ Exploring the reasons for a patient’s demands in a nonjudgmental manner allows most demands to be understood and addressed. Knowing the cause of the demand, a plan that is mutually agreeable can then be negotiated. If such a negotiation is not possible, the patient should be informed of realistic limits to what the clinician can offer. The patient can then decide whether she is willing to accept the clinician’s boundaries or should seek alternative services.

Until there is an agreement on the need for education by clinician and patient, however, the patient might perceive education as the clinician’s way to control the visit.

Once validating the patient’s experience, only then should the clinician give a rationale for why she is not in favor of using opioids for chronic pain: