by Charly Miller, EMT-P

The longer emergency patients experience the devastating sensation that they've "lost control" over their "world," the longer they will suffer increased stress, anxiety, and pain - as well as decreased ability to cooperate with, or positively respond to, the treatment we provide. To arrest and repair such negative effects (as discussed in Parts 8 and 9), as often as possible:

• Offer Choices
  and
• Ask Permission

Remember the "Three Divine Secrets" to restoring a patient's sense of control with choices or by asking permission?

1. Only give a patient a Choice when you don't care what she/he might answer!
2. Never ask Permission to do something that must be done.
3. When Choice or Permission is not an option:
   • Positively explain what will happen
     then
   • Find Something You Don't Care About to Offer as a Choice

   The Fourth Divine Secret:

4. Avoid arguments by agreeing with the patient

Arguments are negative events and never improve a patient's condition. Arguing increases a patient's stress, anxiety and pain. Arguing decreases a patient's ability to cooperate with, or positively respond to, emergency treatment.

Even if the patient eventually gives in to your argument, you can't win an argument with a patient. With the recent advent of greater Customer Appreciation awareness, arguments can easily be recognized as loosing events. When a care provider argues with a patient, the patient may only remember the argument. Hence, arguments are much more likely to generate complaints - even though they may have resulted in the patient receiving more appropriate care.

Avoid argument by agreeing with the patient!

To avoid an argument, simply agree with the patient. This doesn't mean we lose the argument. And it doesn't mean that we let the patient run the call. It means that we supportively voice our understanding of the patient's objections. By agreeing with the patient, we avoid entering into an argument to begin with.

"I don't want an IV!"
"Of course you don't want an IV! Who would? Nobody likes getting stuck with needles - I don't like getting stuck with needles, either!"

"I don't want to go to the hospital!"
"I don't like going to hospitals either! They're frightening places, and you never know what's gonna happen when you go there."

By agreeing with the patient, we've defused the threat of an argument. It is impossible to argue with someone who is agreeing with you.

Next, we should solicit the patient's support and understanding of our need to do something in spite of their objections. To do this, we must explain what is going to happen, and why it's going to happen.

Successful explanations are made in simple English - not medical terminology - and use only positive-sounding terminology. Additionally, explanations of what will happen should always be immediately followed by offering some other choice. A choice the patient can make. A choice that doesn't matter to the patient's care.

"I don't want an IV!"
"...I don't like getting stuck with needles, either! But, I'm worried about your blood pressure being below normal. That indicates you may need fluid or medication to help you get better. If I don't have an IV started, I can't help you feel better.
"I'll start your IV as quickly as possible, and then you'll feel much more comfortable.
"Which arm would you prefer your IV in?"

"I don't want to go to the hospital!"
"...you never know what's gonna happen when you go there.
"That fainting spell isn't normal for you, though. It needs to be investigated, so I'm taking you to get a checkup [more about the "magic word," checkup, in another installment] in the emergency department.
"Are you cold? Would you like another blanket?"

Agreement is an effective method of improving our patient rapport. By agreeing with patients' objections, we demonstrate an understanding of their fears, and congratulate them for being normal.

Agreement followed by explanation allows us to gain a kind of permission for the needed care, and allows us to accomplish what we know is in the best interest of our reluctant patient - without starting an argument.

Remember that competent adult patients have the right to refuse treatment in spite of their medical needs. Thus, it is our duty to honestly and effectively lead them away from bad decisions. It is our duty to help them cooperate with appropriate medical care. The patient's refusal of a needed treatment will not save you from a medical malpractice or negligence suit!

If a patient persists in refusing necessary treatment, simply keep repeating your use of the "Divine Secrets" and proceed with treatment.

Persist in agreeing with them, keep explaining needs for the treatment, and keep offering alternate choices or options, so the patient is allowed some sense of control.

"But, I really don't want an IV!"
"I still hear you! I agree that IVs aren't pleasant! I wish I could take perfect care of you without one. But, your blood pressure says you need an IV, and I'm not going to argue with your blood pressure.
"Are you right handed or left handed? Very good. Thank you. Not a problem.
"I'm happy to put your IV in your left arm so it will be out of your way.
"Would you like another blanket? How about a pillow?"

"I'm telling you! I don't want to go to the hospital!"
"Gosh, I hear you! No one wants to go to the hospital - that's perfectly normal!
"The great thing about going for a checkup in the emergency department is that they are just as eager to send you home as you are to go home!
"The emergency department staff certainly would much rather send you back home. "How about that other blanket? Are you sure you're not cold?"

Notice how the phrase, "I hear you," identifies your recognition of the patient's concerns. "I hear you" suggests that you agree with the patient. It also suggests that the patient has control over the situation, because you're paying attention to their complaint/refusal. "I hear you," is a remarkably successful phrase to use with any kind of reluctant patient.

Remember the "Four Divine Secrets" to restoring a patient's sense of control by offering choices, asking permission, and avoiding arguments:

1. Only give a patient a Choice when you don't care what she/he might answer
2. Never ask Permission to do something that must be done
3. When Choice or Permission is not an option:
   • Positively explain what will happen
     then
   • Find something you don't care about to offer as a choice
4. Avoid arguments by Agreeing with the patient

Remember, it's impossible to argue with someone who is agreeing with you!

In Foundation of Patient Communication Part Six, we discussed the three "magic" words of emergency medicine - words that cannot be said too often: Please, Good and Thank you! In the 11th installment, we'll discuss one of the two "evil" words that prehospital and inhospital care providers must stop using: "The T-Word!"

Email Charly at: c-d-miller@neb.rr.com
Those are hyphens/dashes between the "c" and "d" and "miller"