Aparna S. Nair

Congratulations to Aparna S. Nair, CHT, a recipient of the 2008 Wesley Watkins Scholarship Award

“Managing the Difficult Dialysis Patient”

Over the past 4 years as a dialysis technician, I have looked after a number of patients that could be classified under the broad category of ‘difficult patients’, some occasionally ‘difficult’ while others consistently so. Management of a difficult patient should begin with understanding the underlying issues that trigger the difficult behaviours- the nature of kidney disease and its manifestations, the frustrations and loss of control experienced by the patient among others.

The term ‘difficult’ ascribed to a patient is a broad one that describes a variety of behavioural issues displayed by patients. A significant number of the patients described as difficult is aggressive — most verbally, some physically. A considerable number of patients is non- cooperative, some non-compliant and some very passive about their treatment aspects. Manipulation, self destructive behaviours such as alcohol and drug addiction, sexual aggression and use of profanity also fall under the category of difficult behaviours.

A difficult patient poses a stressful situation and a challenge to the person looking after the patient. A lot of patients experience a loss of control of their lives and feel a sense of powerlessness. Their days are often governed by dialysis sessions and other clinical appointments and often they have to schedule their life activities around these engagements. Patients may also suffer a loss of self esteem due to physical impairment from surgical procedures or as a result of various therapies. Anxiety, language barriers or feelings of inadequacy may also drive abusive behaviours. The knowledge that the complications associated with the disease and its many aspects are largely responsible for the aggressive actions is a big step towards realising the non-personal nature of the aggression. However, personal traits such as one’s ethnicity, age, gender and physical attributes may be targeted during the aggressive outbursts.

Dialysis personnel play a very important role in the management of a difficult dialysis patient. Building a relationship based on trust is of utmost importance. Having compassion for the patient’s condition, willingness to listen to the patients’ problems, acknowledging their situation and being sensitive to cultural differences may help with this.

Any program for successful management of difficult patients should include staff training modules and implementation of effective strategies as well as ongoing participation of both staff and patients. Patient’s agitation is sometimes a result of misunderstandings or misinterpretations and a thorough explanation of facts and use of non-condescending tones may help diffuse the situation. Staff training should include techniques to control their own emotions and to respond to situations in a professional manner without mirroring the problematic behaviour themselves. Retaining a sense of control over the situation as well as supporting each other and other dialysis patients is also important. So is using a slow and clear voice to ask the patient to stop the behaviour and saying ‘no’ when necessary without getting into an argument. It is critical that the staff be consistent while dealing with difficult patients by sticking to the ground rules. Enlist manager’s help and involve security personnel who are trained in dealing with violent persons when necessary. It may also be necessary to discontinue dialysis with the authorization of the doctor in some instances.

Correct and prompt documentation help track of patients’ progress and follow-up procedures to be arranged accordingly. Family and friends sometimes prove valuable in the program and are asked at times to participate in counselling sessions by the social workers. The help of a mental health professional may be required to investigate if psychological factors contribute to difficult behaviours.

In dialysis settings, familiarities develop between patients and carers through regular interactions and the boundaries of acceptable behaviours may be tested routinely either knowingly or unknowingly. Management techniques developed uniquely for such settings when adhered to properly will greatly reduce the stress levels associated with difficult situations and thus create a more stable and safe clinical atmosphere. Regular review of the developed strategies and ongoing staff training will ensure that the implementation of those strategies has been most advantageous from both staffs’ and patients’ points of view and that patient care is compromised to the least possible degree.


  • Managing the difficult patient: practical suggestions from a study day R.H. Corney, G. Strathdee, R. Higgs, M. King, P. Williams, D. Sharp, and A.J. Pelosi J R Coll Gen Pract. 1988 August; 38(313): 349-352.
  • Victorian Renal Nurses Symposium Aug 2008, Melbourne, Australia
  • National Ethics Teleconference, Managing “Difficult” or “Non-Compliant” Patients: Ethical Challenges, September 26, 2001

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