Responding to threats

Mark seemed a little edgy during the consultation and you’re not sure if this is normal for him. You proceed with the consultation and give Mark his repeat script.

Mark makes a passing comment under his breath as he’s walking toward reception muttering, “It would be easier if I just topped myself…”.

The comment takes you by surprise, and you’re not sure how to respond because the next patient is already making their way into the consultation room. You carry on seeing patients, but Mark’s comment is still playing on your mind.

Medico-legal discussion

One of the most challenging components of medical practice is often the ‘people’ part. In the heat of the moment, it can be challenging to read a situation and respond effectively, particularly in circumstances where you fear the wrong response could provoke the patient.

Threats by patients (against themselves, you, or others) can present in different ways, and it is important to be prepared to respond to these threats as effectively as possible.

Breaching confidentiality

Under Australian privacy law, you can disclose health information where “it is unreasonable or impracticable to obtain consent to the use or disclosure of that health information, and you reasonably believe the use or disclosure is necessary to prevent a serious threat to life, health or safety of any individual, or to public health or safety”. This may include a call to the police to undertake a welfare check on a patient or report a potential crime.

Threat assessment

Having a few ‘go to’ lines can be a handy way of gauging risk and de-escalating the situation. This allows you time to think through your options, or to obtain advice from a colleague or MDA National.

It is important to remain calm and measured to ensure you can clearly assess the situation and any potential risk the patient might pose. Asking the right questions could alleviate your concerns, particularly if the patient is just blowing off steam. De-escalation skills come with practice, and situations like this can be very uncomfortable, particularly if patients start to swear or become irate.

Personal safety is paramount – so if you don’t feel safe you should remove yourself from the threat, alert practice staff, and call the police. Avoid heated arguments and physical contact. These situations can be very stressful, and it might take some time to process your thoughts. Once the immediate threat has passed, call MDA National to debrief and seek advice on next steps.

General de-escalation tips

• Try and use the patient’s name, stay calm, and attempt to bring the temperature down.
• Offer the patient a break in the consultation, but use this technique with caution; the patient may leave the practice in a heightened state without any resolution or safety plan in place.
• Use open questions and don’t be afraid to clarify points made by the patient if you have ongoing concerns.
• Avoid blocking entrances or exits, or trying to restrain the patient, as this can escalate the tension and lead to a physical altercation.

No two cases are the same, but we’ve set out examples on how you could respond to some of the tricky situations you might come across:

 

“I’m so angry, I could stab someone!”

• “Hey, can we talk a bit more about that?”
• “If you genuinely mean that, I may have an obligation to alert the police.”

 

“I wish she was dead.”

• “Please don’t joke about things like that. What do you mean?”

 

“You know I’ve got a gun at home?”

• “What are you suggesting?”
• “Do you intend to use the firearm on yourself or someone else?”

 

“Just give me some more codeine and nobody gets hurt!”

• “Who do you intend to hurt?”
• “I can’t provide you with care if you’re going to threaten me. Let’s talk about your current symptoms and then we can discuss appropriate treatment.”

 

“Don’t you dare push me over the edge!”

• “I’m here to help you; can we talk about what’s making you feel that way?”

 

“It doesn’t matter…”

(If you ask the patient to repeat what they’ve said)

• “I’m doing my best to help you – can you repeat what you said?”

Case study - outcome

During a break between patients, you call the contact number on file for Mark and he answers your call.

“I was a little concerned about a comment you made as you were leaving the consultation today – I just want to check that you are okay.”

Mark apologises and confirms he was having a bad day; he is not suicidal or making any plans to harm himself; and he is grateful for the follow-up call.