Problematic Behaviors of Patients, Family, and Staff in the Intensive Care Unit

Craigan T. Usher

The ear says more

Than any tongue.

—W.S. Graham, “The Hill of Intrusion”

Whether a patient being treated in the intensive care unit (ICU), a supportive family member, or a physician or other healthcare professional working there, it is clear that the ICU is a stressful environment [1,2,3,4,5]. Problematic communication among patients, their families, and the hospital staff can hinder the restoration and maintenance of basic life functions that are the hallmark of intensive care. Occasionally, such difficult patient–staff or family–staff interactions stem from problems with care providers themselves. Depression, anxiety, overwork, sleep deprivation, longstanding interpersonal rigidity, and the cumulative effects of stress may cause some physicians and nurses to fail to address adequately the emotional needs of their patients and patients’ families [6,7,8]. In other instances, patients and families become overwhelmingly stressed, their judgment and interpersonal skills rent asunder by longing, shame, rage, and despair. Such patients and family members may then act in ways that are irritating or even dangerous.

This chapter presents approaches to problematic patient conduct in the ICU, details common patterns of exasperating behavior in critically ill patients, provides practical ways of dealing with them empathically, and outlines some effective modes of communication with families of patients in the ICU. Above all, this chapter emphasizes that listening to patients and family members, paying special attention to the psychological needs underlying problematic behavior, and attempting to meet those needs make better patient–doctor/family–doctor relationships possible.

Approach to Problematic Behaviors

Critically ill patients can behave in disruptive ways that jeopardize ICU activity and treatments. Some patients become childlike, cry or whimper, turn away from care providers, and refuse examinations or procedures. A number of patients grow demanding of nurses’ and physicians’ attention; they hurl insults when providers are not as attentive as they would like. Others may be violent, threatening staff, even punching and kicking caretakers.

Before deciding how to approach the disruptive patient, one must first answer the questions “Do I feel safe?” and “Is the patient safe?” ICU personnel learn to override their fears as they perform procedures that demand brisk, decisive action. Unfortunately, such denial occasionally leads to failure to heed an internal alarm regarding patient behavior, resulting in injury to patients and staff. Hence, it is key to “tune-in” to this sense of peril when acute danger to a patient or others exists and then to administer calming medications, summon security personnel, and apply physical restraints if necessary [9]. Physical confrontation with a non-delirious patient can sometimes be avoided by calling security personnel expeditiously, as merely seeing several officers, patients recognize the seriousness with which staff is approaching their threats or actions—and then relax.

For example, emerging from delirium after a near-lethal toxic ingestion, an impetuous adolescent threatened to “beat up” staff if not permitted to leave the ICU immediately. When hospital security arrived and the physician informed the young patient he would have to wait, the teenager quickly sat back in bed. Asked by the psychiatric consultant why he had calmed, the young man explained: “When it was just the nurses and doctor, I thought I could take them. But I knew I wasn’t going anywhere when the police arrived. So I chilled.”

Once the safety of the patient, other patients, and staff is ensured, examination of underlying causes of a patient’s taxing behavior follows. As irritability and emotional lability are the final common pathway of myriad medical and psychiatric conditions and of normal emotional responses, precise determination of the cause of a patient’s disruptive behavior is often vexing. Asking and answering the questions listed in Table 201.1 can be helpful in narrowing the vast differential diagnosis.

Delirium is a common source of troublesome patient behavior in the ICU. Patients who are hallucinating or harboring persecutory delusions that ICU staff is torturing them can be immensely problematic. Due to its potentially lethal nature [10], delirium should be ruled out first as the driving force behind a patient’s disruptiveness. A full discussion of delirium is provided in Chapter 197.

After delirium has been excluded, it is important to look for major psychiatric illnesses, which are frequently exacerbated by the chaos, vulnerability, and prolonged inner tension associated with being treated in the ICU [11]. The intensivist should discern if the patient has a history of psychotic disorder, affective illness, or anxiety disorder and, in the absence of contraindications, should order any medications that have been effective in treating these conditions in the past. As part of this psychiatric workup, a substance-use history is also imperative; data from collateral sources may be necessary to confirm the patient’s report. At any step in the process of assessing the roots of patients’ problematic behaviors, psychiatric consultation may be useful in establishing and confirming diagnoses and in guiding treatment.

While gathering data about psychiatric conditions and substance use, common sources of patient stress in the ICU (e.g., pain, sleeplessness, and isolation) should be eliminated, as much as possible. Biancofiore et al. showed that liver transplant recipients and patients who underwent major abdominal surgery identified “being unable to sleep, being in pain, having tubes in nose/mouth, missing husband/wife, and
seeing family and friends only a few minutes a day as the major stressors” [12]. Provision of adequate analgesia, effective sleep aids, anxiolytic agents, and uninterrupted interaction with significant others often substantially curtails problematic behaviors.

Table 201.1 Key Questions About Behavioral Problems in the Intensive Care Unit

Safety
   Is the patient’s behavior dangerous? If so, how can I keep the patient and others safe?
Delirium
   Is the patient delirious? If so, am I effectively treating the underlying causes of delirium?
Psychiatric illness
   Does the patient have an anxiety, mood, or psychotic disorder or other psychiatric illness? If so, am I providing adequate treatment for these conditions?
Intoxication and withdrawal
   Is the patient intoxicated with or withdrawing from alcohol or other substance? Am I addressing the untoward effects of withdrawal?
Psychosocial stressors
   Can I reduce pain, sleeplessness, isolation, and other stressors related to being in the ICU?
Personality problems
   What is the patient’s predominant mode of coping? How can I best manage this patient’s uniquely taxing coping strategies?

Table 201.2 Common Problematic Coping Styles of Patients and Family Members in the Intensive Care Unit

Personality type	Core deficit	Characteristic behavior	Suggested response
Dependent	Hypersensitive to abandonment, inadequacy, and aloneness	Craves attention Demands special care Childlike Cries easily and complains of abandonment and inadequate care	Schedule examination and rounding times Anticipate nursing staff changes, physician care shifts, transfer to floor Validate patient’s plight and offer to help within reason
Narcissistic	Hypersensitive to loss of control and stature Defended against looking weak	Denies severity of illness Shows bravado Critical of ICU staff and care	Acknowledge patient’s stature Enlist patient as active partner in care and decision-making
Obsessive	Hyperaware of loss of control Defended against looking weak	Excessive focus on medical facts and minutiae Restricted affect Not apt to “show emotional cards”	Schedule patient and family meetings Have a set amount of information to share with patient and family Provide factual explanations of data Avoid emotional commentary or inquiry
Dramatic	Difficulty feeling cared for or thought of except within emotionally extreme exchanges	Engaging and charming to some staff, denigrating and caustic to others May have multiple allergies and phobias May “fire” some staff and take exception to rules	Acknowledge patient’s positive attributes Validate patient’s plight and offer to help within reason Set limits as a team
Adapted from Kahana RJ, Bibring GL: Personality types in medical management, in Zinberg NE (ed): Psychiatry and Medical Practice in a General Hospital. New York, International Universities Press, 1965, p 108.

Common Patterns of Problematic Behavior

Critical illness leads many patients to feel lonely, dependent, or anxious about the prospect of death; traumatic memories may be reawakened as well. To keep these unpleasurable feelings and recollections at bay, ICU patients deploy a broad array of psychological defenses. Some patients’ patterns of defense—that is, their personalities—are quite adaptive, even at times of stress. Other patients are devoid of the healthy emotional protoplasm, reliable social supports, and ample psychological armamentarium required to deal well with adversity. Such patients may be said to suffer from psychosocial insufficiency. Through denial, devaluation, passive-aggressiveness, and other primitive defenses [13], these patients are prone to wreak havoc in the ICU.

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