When Patients and Their Families Feel Like Hostages to Health Care

Abstract

Patients are often reluctant to assert their interests in the presence of clinicians, whom they see as experts. The higher the stakes of a health decision, the more entrenched the socially sanctioned roles of patient and clinician can become. As a result, many patients are susceptible to "hostage bargaining syndrome" (HBS), whereby they behave as if negotiating for their health from a position of fear and confusion. It may manifest as understating a concern, asking for less than what is desired or needed, or even remaining silent against one's better judgment. When HBS persists and escalates, a patient may succumb to learned helplessness, making his or her authentic involvement in shared decision making almost impossible. To subvert HBS and prevent learned helplessness, clinicians must aim to be sensitive to the power imbalance inherent in the clinician-patient relationship. They should then actively and mindfully pursue shared decision making by helping patients trust that it is safe to communicate their concerns and priorities, ask questions about the available clinical options, and contribute knowledge of self to clinical decisions about their care. Hostage bargaining syndrome is an insidious psychosocial dynamic that can compromise quality of care, but clinicians often have the power to arrest it and reverse it by appreciating, paradoxically, how patients' perceptions of their power as experts play a central role in the care they provide.

Why are patients not more involved in their own safety? A questionnaire-based survey in a multi-ethnic North London hospital population

“…Our data suggest that our patients find it more difficult to raise issues in a directly confrontational situation (eg, healthcare professionals’ hand hygiene [Q14] or insisting that they check identity before dispensing medication or doing procedure [Q15]) compared with more passive ones (such as bringing a summary of current medication [Q4] or inquiring about side effects of new medication [Q8]). Patients can exhibit excessive deference to hospital staff because of their cultural background and for fear of being labelled "difficult" or "troublesome" 20. Data collated from our questionnaires confirmed previous findings from Davis and colleague12 21 that patients with higher levels of education express more willingness to participate in safety-related behaviours, possibly due to the fact that less educated patients over-rely on health professionals, who can make inadvertent errors.…”

The impact of a patient decision aid on shared decision‐making behaviour in oncology care and pulmonary medicine—A field study based on real‐life observations

“…They felt that the health care professional presented a specific treatment course, which they needed to accept and follow . Also, many cancer patients are reluctant to assert their interests and preferences leading to a feeling of “hostage bargaining syndrome.” Thus, even a slight improvement in eliciting the patients' preferred level of involvement in decision making will make a difference.…”

“…It seems that patients often suppress their needs to avoid burdening the health care professionals, and Berry et al illustrate how patients are often reluctant to assert their interests and preferences in the presence of clinicians. Especially in decisions about treatment or care for serious illness such as cancer, many patients are susceptible to the “hostage bargaining syndrome.” This may manifest as understating a concern and asking for less than desired or needed . Hence, capturing patient preferences and achieving SDM can be very difficult.…”

Ambitions for palliative and end of life care: a relentless focus on the person

“…First, we need to acknowledge the reality of what Berry et al called a hostage bargaining syndrome [21]. They describe how patients and their families may hold back from open engagement and robust discussion with clinicians that is needed for genuine shared decisionmaking, behaving like hostages, negotiating from a position of fear and confusion.…”