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Thursday, 24 January, 2002, 12:16 GMT
The dilemma of treating difficult patients
A&E department
A&E departments can be tense places
Rose Addis's case highlights the dilemma for front line A&E staff who have to deal with difficult patients.

Cases where people refuse treatment are usually rare, but where they do occur they test staff's diplomatic skills to the limit.

They have to balance a patient's wishes with medical needs.

In most situations, it is usually an excess of alcohol which leads to resistance and once the effects wear off, the patient becomes more reasonable and allows treatment to go ahead.

We have to respect a patient's wishes, but do the best we can to reach a compromise

John Heyworth, British Association for A&E Medicine
But situations can occur where a patient needs life saving treatment but refuses to let medical staff intervene.

The British Association for A&E Medicine (BAEM) says staff have to go through several procedures, up to and including legal action if they believe it is necessary.

BAEM president John Heyworth said: "All the time you try to do what's best for the patient.

"Where situations aren't life threatening, we have to come to some arrangements.

"It's important to talk to the relatives because quite often they can persuade the patient to accept treatment.

"But that doesn't always work and there are times when we aren't always able to do exactly as we wish.

"We have to respect a patient's wishes, but do the best we can to reach a compromise."

Staff training

Life threatening situations are very different and while staff spend time negotiating, vital seconds are slipping away.

Mr Heyworth said: "We have a fundamental principle to preserve life.

"It's sometimes necessary to go to court, but hopefully we are able to discuss it with relatives.

"But it is a difficult legal issue. It's very difficult to force a patient and it's illegal and it could lead to a claim for assault."

Nothing can prepare you for what you are likely to encounter in an inner city A&E... you're facing battle zones

Michael Walker, Unison
Staff training on how to deal with these stand-offs, is a bit patchy, according to the health union Unison.

Unison's London nursing officer Michael Walker said: "Basic nursing training has very little on how to deal with abusive patients and those refusing treatment."

Mr Walker said there are a number of post basic training courses for nurses in this area, but staffing shortages in A&E departments prevent them attending.

He said: "It's almost impossible to get time off to go on these courses and yet they are a necessity.

"Nothing can prepare you for what you are likely to encounter in an inner city A&E.

"In A&E you're facing battle zones."

The BAEM believes dealing with difficult patients is a matter for more senior staff.

Mr Heyworth said: "It is an issue we would expect to be referred up.

"Senior staff would have had more experience and are aware of the issues involved.

"But I'm confident staff are equipped to deal with these situations."

The BBC's Daniel Sandford at Whittington Hospital
"After years of underfunding, A+E departments are badly stretched"
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