Annotated Abstracts of Journal Articles
2014, 4th Quarter


Annotations by Paula Zimbrean, MD, FAPM and Marta Novak, MD, PhD
December 2014

  1. Managing disruptive behavior by patients and physicians: A responsibility of the dialysis facility medical director


PUBLICATION #1 — Psychonephrology
Managing disruptive behavior by patients and physicians: A responsibility of the dialysis facility medical director

ANNOTATION (Zimbrean & Novak)

The Findings:  This is an opinion review paper analysing variants of disruptive behavior (both patient and physician) in the dialysis setting.

Strengths and Weaknesses: The main strength of the paper consists in its ability to connect the clinical aspects of disruptive behavior with the legal implications of such events.

Relevance: Psychosomatic medicine practitioners are often involved in clinical and administrative decisions regarding patients who display disruptive behavior during their dialysis treatment. This article provides a framework for approaching such disruptive behavior, including identification of the behavior and of possible causes, clinical interventions, and administrative interventions, including involuntary discharge or transfer.


The Centers for Medicare & Medicaid Services’ Conditions for Coverage make the medical director of an ESRD facility responsible for all aspects of care, including high-quality health care delivery (e.g., safe, effective, timely, efficient, and patient centered). Because of the high-pressure environment of the dialysis facility, conflicts are common. Conflict frequently occurs when aberrant behaviors disrupt the dialysis facility. Patients, family members, friends, and, less commonly appreciated, nephrology clinicians (i.e., nephrologists and advanced care practitioners) may manifest disruptive behavior. Disruptive behavior in the dialysis facility impairs the ability to deliver high-quality care. Furthermore, disruptive behavior is the leading cause for involuntary discharge (IVD) or involuntary transfer (IVT) of a patient from a facility. IVD usually results in loss of continuity of care, increased emergency department visits, and increased unscheduled, acute dialysis treatments. A sufficient number of IVDs and IVTs also trigger an extensive review of the facility by the regional ESRD Networks, exposing the facility to possible Medicare-imposed sanctions. Medical directors must be equipped to recognize and correct disruptive behavior. Nephrology-based literature and tools exist to help dialysis facility medical directors successfully address and resolve disruptive behavior before medical directors must involuntarily discharge a patient or terminate an attending clinician.

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