Ch 18 - VULNERABLE PATIENTS

Introduction
Some social characteristics that affect patients health
Living in poverty
Low-level education
No health insurance
Speaking little English
Patients in these groups are more likely to
Contract illness
Face obstacles in the care of that illness
Receive suboptimal care (if available)
Experience health risks in clusters
E.g., Individual living in poverty, w/ low-level education, uninsured, having simultaneously diabetes,
heart disease, and depression, and having limited access to high-quality grocers and safe outdoor
space for physical activity.
Strategies to promote effective care for vulnerable patients
(1) Building a therapeutic alliance
(2) Eliciting the patient's story or narrative
(3) Assessing for the patients psychosocial vulnerabilities and strengths
Pathways by which psychosocial vulnerabilities affect health and health care in the clinical encounter
The vulnerability in and of itself leads to poor health (direct pathway)
E.g., intravenous drug abuse leads to skin abscesses
The vulnerability affects the medical condition (indirect pathway)
E.g., Nonadherence to CHF medications due to depression
The vulnerability affects the relationship w/ the provider (indirect pathway)
It limits the benefits of a collaborative relationship on care
E.g., undisclosed illness that is inconsistent w/ a prescribed tx plan
Its mediated totally by t herapeutic alliance
What is therapeutic alliance?
It exists when pt and provider develop mutual trusting, caring, and respectful bonds that allow collaboration and care.
Base for patient-centered and relationship-centered care
It includes:
Mutual trust
Pts need to trust in their clinicians integrity and competence
Clinicians need to trust that pts will try to do their best
Empathy
Recognizing and understanding the beliefs and emotions of another w/o injecting ones own
Respect
Respecting and treat pts w/ dignity
Collaboration
Pts and clinicians working together toward a common goal
It must be broadened beyond pt-clinician relationship
Ex. of important people that should be included
family, health coaches, consulting clinicians
Health systems can foster or erode the therapeutic alliance based on the policies they promote.
Therapeutic Alliance and Vulnerable Patients
It has its most profound benefits w/ vulnerable patients
It empowers patients and reduces barriers to their care
Empowerment
Vulnerable pts often experience broken and disrupted relationships
Due to violence, immigration, mental illness, homeless, illness
Through the therapeutic alliance, clinicians can offer
Reliable, continuous, dependable presence

 Support, acceptance, nonjudgmental attitude

Safely
Validation to pts experiences
In supporting pts as competent and strong, clinicians can help empower them to become actively
involved in their care.
Access to care and related resources
Vulnerable pts often face limited access to health care and social services
Lack of knowledge about what is available
Inability to deal with bureaucratic health systems
Through the therapeutic alliance, clinicians can help pts
To feel safe enough to reveal concerns beyond the present problem
E.g., Diabetic pt who drinks alcohol regularly and lives w/ abusive partner
Knowing about these problems, clinicians can facilitate entry into the
various health and social systems that can help address these
vulnerabilities.
What Can Happen When the Therapeutic Alliance is Absent?
It results in serious consequences for the health of vulnerable patients
Trust
Absence of a trusting relationship leads to difficulty in achieving true collaboration between pts and clinicians
Pts may withhold their beliefs and values about a suggested tx
Vulnerable patients may enter into the relationship with a degree of mistrust
Clinicians should earn trust by:
Being transparent
Clinicians should explain the reasons for some personal questions
Vulnerable pts often experience external intrusion and may not understand why
clinicians ask about personal information
Explaining why one is recommending a particular diagnostic course or tx regimen can also
build trust
Following through
By taking the extra time to follow-through on promises, clinicians can show pts that they can
be counted on to ensure the best care
E.g., My homework after your last appointment was to find out about
Spanish-speaking support groups for pts with diabetes; there is one not too far from
your home
Addressing concerns
Clinicians should show they are interested in helping the pt and can be trusted to care
E.g., take time to answer questions and focus on what the pt needs
CARING
Poor and minority pts often receive care in teaching hospitals and community health center
In these places, pts may question providers motivation and commitment
When clinicians persuasively argue for unwanted treatments, vulnerable pts may fear being
used as experimental guinea pig
Rather than risk raising concerns, pts may not return for care or follow-through on
recommended tx
RESPECT
Perceived disrespect and discrimination has been associated w/ lower satisfaction w/ the health care system
and worse health outcomes among pts w/ chronic illness
MUTUAL AGREEMENT AND COLLABORATION
Can be achieved by
Presence of a trusting relationship
Sharing decisions
Treating pts w/ respect and dignity

Being treated w/ respect and dignity may be more important than engaging in shared
decision making, and may itself lead to positive outcomes (e.g., higher satisfaction)
Building a therapeutic alliance w/ vulnerable pts
Demonstrate commitment to the relationship
Clearly state your desire to be available to your pts within the scope of your practice
Be clear about what you do for the pt between visits
Follow -through as promised
Allow for the humanity of the pt and the clinician to emerge
Sharing of beliefs, values, and feelings as they relate to the clinical issues facing them
Offer self-disclosure to identify a share hx or common interests w/ pts
Elicit pts stories or health narratives
This approach can provide critical insights into a pts illness model, allow for expression of the pts humanity,
and uncover psychosocial vulnerability
Search actively for pts strengths and resources
Validate pts strengths and resilience
Use the pts resource as a starting point for healing
E.g., You have talked about turning to God when dealing w/ other major crisis in you life; have you
thought of doing the same now?
Express caring overtly
Acknowledge the pts perspective
Use nonverbal behaviors/statements
Body language
Sitting in proximity
Focused, unhurried posture
Active listening and reframing
Support
Validation
Make an unexpected phone call
Respecting physical contact during painful or uplifting moments
Create a context for conflict to emerge and get addressed
Adopt nonthreatening ways of communicating differences w/ their pts
Clarify boundaries
Explain why we are inquiring about certain informations
Clarify our own boundaries
To avoid unhealthy dependency and unrealistic expectations
Address the therapeutic alliance directly
If pt is doing poorly but receiving optimal medical care, ask if the pt would want any changes in the
relationship
Eliciting the Patients Story or Narrative
Patients perspective
Complex mixture of very personal beliefs, values, and assumptions reflecting multiple influences
Shaped by many factors
Individual, familial, societal, spiritual, cultural
The same factors that influence how people think about health and illness also impact other aspects of their
lives
Knowing these influences can uncover perspectives important to health care
E.g. ones explanation of life difficulties and the narrative of how one has prevailed over them may
illustrate how one will face challenging health problems as well
Illness may be framed hopefully or pessimistically
Pts may see themselves as victims or as efficacious
They prefer being independent or isolated
They may find strength in support from others
Importance of eliciting the patients perspective

It can determine how pts develop a relationship w/ their clinician, and if they feel understood and respected
or misunderstood and discounted.
It allows for accurate empathy
It can uncover interests or experiences
It can improve pt trust, satisfaction, and adherence
In contrast w/ clinicians perspective
Clinicians should not assume a shared understanding
They should explore the differences by eliciting the pts story or narrative
Assessing & Acknowledging Psychosocial Vulnerabilities
Patients social context
One of the most important and frequently least appreciated factors
It can impinge on a pts ability to carry out the tx plan and interfere with their therapeutic alliance
How to assess psychosocial vulnerabilities
Be nonjudgmental
Allow the pt to respond at his/her own pace
Use open-ended questions
Respond to pt cues

Caveats
When trying to discover the pts psychosocial vulnerabilities, also try to identify and acknowledge the pts
strength, resilience, and range of resources
Vulnerability is context dependent
E.g., lack of insurance is not a vulnerability in countries with universal health care coverage.
Clinician should be aware that the pts vulnerability may lead to shame and stigma
E.g., Having limited literacy may elice feeling of shame
After identifying vulnerability, explore w/ the pt (in a supportive, nonjudgmental manner) how the vulnerability
may be affecting health and care and how to mitigate these effects.
Differential diagnosis of psychosocial vulnerabilities
Violence
Uninsured
Literacy and/or Language barriers
Neglect
Economic hardship
Race/Ethnic discordance, discrimination
Addiction
Brain disorders (e.g., depression, dementia, personality disorder)
Immigrant
Legal status
Isolation/informal caregiving burden
Transportation problems
Illness model
Eyes and Ears (vision, hearing problems)
Shelter

Sustainability in Building the Therapeutic Alliance with Vulnerable Patients

Strategies useful in developing and sustaining a therapeutic alliance w/ socially vulnerable pts
Showing pts in concrete ways that you care
Advocating for pts w/ the myriad bureaucracies/ which they struggle
Connecting them w/ appropriate community resources
Networking w/ others (e.g., family, friends, public health, community resources)
Encourage them to support the pts effort others
Engaging in self-disclosure
To narrow social distance and encourage the sharing of personal stories
Caveat
Developing patterns of codependency may be a prelude to clinician burnout
E.g., always rescuing pts from the decisions that are in their control
Signs of burnout
Exhibiting their anger and frustration at pts, staff
Developing an overly passive style of pt engagement
How to minimize burnout and maximize sustainability when caring for vulnerable populations
Personal, interpersonal, and environmental support
Personal motivators
E.g., personal growth
Careers motivators
E.g., work-life balance and loan repayment assistance
Environmental factors
Supportive interprofessional colleagues and teams
Establishing an understanding of pt expectations
Setting realistic goals
Limiting what needs to be accomplished in any given encounter (the work evolves over a long
period of time
Continuously clarifying boundaries
Maintaining a sense of curiosity and discovery about the pts clinical and personal profile
Acknowledging that the pts problems may not always be a result of patient choice
Engaging in public health-related or social advocacy efforts to affect structural determinants of
health