The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 10: Psychiatric ProblemsTable 10-27: Strategies for Managing Difficult Patients• Identify the nature of the treatment problem: Pain? Cognitive impairment?Irritability? Non-adherence? Devaluation? Underlying depression, anxiety orpsychosis?• Establish and identify the treatment team and have the patient sign a consentfor free and unrestricted communication among ALL providers, within thesame system and outside (e.g., methadone treatment program staff, casemanagers, housing authority staff).26 picas• Establish concrete treatment goals that are reasonable and can be renegotiatedat specified time intervals.• If at all possible, establish an agreement regarding pain management beforethe need for pain treatment actually begins. Write a pain managementcontract with rules spelled out regarding refills, how doses will be determinedand increased, which meds will and will not be used.• Set limits on refilling prescriptions, identify which provider will be responsiblefor which medications, and who will be covering when the primary prescriberis away. Also set limits on how and when patients should access their primarycare provider vs. their mental health provider, person on call, or emergencyservices.• Establish rules of behavior for the clinic’s entire patient population. Identifywhat behavior will not be tolerated and enforce the rules fairly and withoutindividual variation. Have the limits for behavior clearly spelled out andapproved by a consumer advisory board or patient constituency group.• When a patient is admitted to the hospital for medical care or psychiatric care,establish contact with the treatment staff to discuss rules regarding limitsetting,making goals clear and responding to patient requests without bias.• Provide a space for clinicians to share feelings and thoughts about difficultpatients. Knowing that one is not alone in having trouble with a particularpatient can be comforting and prevent acting out on the part of the provider.HIV-Associated Syndromes with Psychiatric ImplicationsSeveral HIV-associated syndromes such as wasting, fatigue, sexual dysfunction and pain havepsychiatric implications. As with sleep disturbance, treating complaints that are important topatients and that affect cognitive functioning will increase patient adherence to care and helpbuild a therapeutic alliance between patient and provider. Pain and fatigue are discussed elsewherein this guide. (See Chapter 4: Pain and Chapter 5: Constitutional Symptoms.)Wasting syndrome and sexual dysfunction are often associated with impaired self image, a senseof being defective, and body dysmorphia. These feelings can lead to obsessional concerns andbehaviors. Testosterone replacement may be beneficial in these settings. 87,88 While testosteronemay improve libido, it may not address all sexual dysfunctions. Underlying problems such as244U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau