Case Study: Patient C
Patient C was a 59-year-old woman who was admitted to the hospice unit from a local hospital. She had a long history of abdominal mesothelioma, and 2 years prior to admission, a biopsy of a lung mass was diagnosed as adenocarcinoma. She refused any treatment. More recently, she had complaints of headache, left-sided weakness, and recurrent falls. She then was found to have a large right frontal brain mass with vasogenic edema and midline shift. Once again, she refused all cancer-related treatment. She was placed on dexamethasone to control brain swelling and levetiracetam to manage seizures, and was referred to the hospice unit with a poor prognosis.
In addition, Patient C had a history of BPD and had required psychiatric hospitalization in the past. The hospice team was informed that during past mental health admissions, she had been challenging behaviorally. She was verbally abusive to staff and physically assaultive, and she often refused medications and care. She was homeless and had failed various attempts at placement related to her behavioral issues. She was single and had two children who were, until this time, peripherally involved. She had no other friends or family related to stormy relationships over time.
After admission to the hospice unit, Patient C told staff that she was pleased to have a lovely place to stay and that she would do her utmost to follow the rules and get along with everyone. However, within a few days, she was screaming obscenities and insults at the staff and throwing dirty linen at them. She told some staff that they were her favorites and others that they could do no right.
Patient C showed frequent disregard for unit rules. She plugged toilets, smoked cigarettes in her room, hoarded and hid food that spoiled, smoked off the unit at night after curfew, and turned the television on full volume in the middle of the night. She frequently refused medications and treatments. When approached by the hospice provider in her room for assessment or discussion, she would face the wall, refusing to acknowledge the provider's presence. Alternatively, she would storm into the provider's office suddenly and unexpectedly with complaints or issues at any time of the day.
Nordgren (2007) reported the symptoms of BPD are exacerbated by stress. These symptoms can alarm staff. One common symptom encountered is that of splitting. Splitting is a coping defense mechanism that individuals with BPD use to avoid being rejected or hurt. Splitting means that others are viewed as either good or bad. The patient's rigid approval of and cooperation with “good” caregivers and scorn for “bad” caregivers can lead different hospice team members to experience the patient differently. In addition, these alliances may shift rapidly with minimal justification. If splitting is not recognized, hospice team members may disagree about various aspects of the patient's care, such as validity of symptoms and need for medication. The team can descend into discord with resulting inadequate communication and inconsistent care. Team members may take sides either for or against the difficult patient (Hay & Passik, 2000).
Although most inpatient hospice clinicians are skilled in meeting the holistic needs of terminally ill patients, they are less equipped to manage the behavioral symptoms of BPD. A psychiatric consult–liaison, additional training, and support can help team members feel better prepared to work with these patients and alleviate negative responses to them (Bland et al., 2007). In this case, the palliative psychologist provided the education and support the team clinicians needed. The team learned about the complex etiology of BPD, common behavioral symptoms, and appropriate responses. The team learned splitting was not just a thing that happens but was a process that clinicians were responding to and experiencing with Patient C.
The psychologist worked with staff to examine their own reactions to the splitting behavior and to respond in a respectful and empathetic but consistent and neutral manner. Staff members who were on the front line, such as nursing assistants and housekeepers, were involved with treatment planning. They were encouraged to call on a colleague for substitution if they needed to regroup or to avoid feeling overwhelmed. Other interventions for splitting behaviors have been suggested in the literature. Feely et al. (2013) developed and modeled a script that staff could use to respond to behavioral disruptions. James and Cowman (2007) recommended the use of standard treatment protocols for BPD in inpatient and outpatient settings.
Setting boundaries for individuals with BPD is essential to minimize disruptive behaviors and staff burnout. Hill (2005) defined clinical boundaries as limits that protect the relationship between the nurse and the patient. Boundaries have several desired outcomes. First, boundaries keep the focus on the patient's needs and problems rather than allowing the patient to shift the focus back to staff or to other issues. Second, boundaries ensure that the relationship is goal-directed (i.e., peaceful death). Finally, boundaries confirm that the relationship is objective rather than subjective and that staff are not personalizing their reactions to difficult behaviors.
In this case, the team used several types of boundaries to curtail problematic conduct. One way to set limits is with contingency management; this involves spelling out “if X behavior happens, then Y consequence will occur.” The behaviors and consequences can be either positive or negative. Patient C was informed that her room was unkempt, smelled from spoiled food, and contained contraband such as hidden cigarettes. She was told that if contraband and spoiled food were found again, staff would intervene twice daily to remove these items and clean the room. When these items were found, twice-daily health and welfare checks were performed by a nursing staff member and the housekeeper. Two staff were present to prevent accusations of stealing. Patient C also was told that if she knocked on the provider's door and was asked to enter, then the provider would either meet with her at that time or make an appointment to see her later that day. If she barged in uninvited, she would be politely asked to leave.
Cigarette smoking also required limit setting. The team told Patient C that tobacco use risk assessments would be performed weekly. If she was noted to be unsafe with her smoking materials, then smoking privileges would be revoked. As she deteriorated functionally, this did happen, and a nicotine patch was prescribed. When her family visited, they escorted her to the smoking area at which time the nicotine patch was removed.
Patient C refused medications considered essential to manage her cancer-related symptoms. She complained of headaches related to her brain mass but refused oral steroids and pain medications. She had significant edema of her legs but refused diuretics. She adamantly refused any psychotropic medications. Nordgren (2007) described patients who are medically noncompliant as “help rejecting complainers” (p. 379) and labeled this behavior as noncollaborative. Yet, as symptoms mounted with disease progression, partnership toward the goal of a peaceful death was necessary.
There were ongoing efforts to educate Patient C about how various treatments could ameliorate uncomfortable symptoms, and compromise happened often. For example, Patient C refused to continue to take the oral steroid medication because she did not like the increased appetite or weight gain that she experienced. The provider explained that this drug had improved her left-sided weakness such that she was walking independently again, speaking more clearly, and achieving relief from headaches. She then agreed to take a lower dose, and the dose was adjusted as some steroid was better than none.
She also initially refused to take any oral opioid for ramping pain, but she agreed to subcutaneous morphine. Because pain relief was the goal, the provider went with what she would accept at first. Eventually, she agreed to the conversion to an oral opioid. Unlike most patients, Patient C preferred diuretic dosing in the evening and this was arranged.
Gradually, as a therapeutic alliance was achieved and she became physically more comfortable, Patient C gave the provider more latitude with medication adjustments. She remained on the unit for 6 months. She mellowed with time as her physical needs intensified, and she died peacefully with her family at her side.