I want you to help me, but you will do it my way.....

[Daisy Doodle]

How do you deal with indignant patients that come to the Emergency Department asking for help and then refuse certain aspects of care.

Lately, I have had numerous patients simply refuse to put on a patient gown, they simply do not want to be bothered by putting on a gown. Most of our physicians really want (demand) patients be in a gown no matter the chief complaint. Then the physician comes out of the room and says, "she not in a gown, I want them in a gown".

I also have patients complaining of chest pain, so we start our chest pain protocol and then they say, no I won't wear this oxygen, no I don't want an IV, no I won't put on this gown, and why do I need an EKG. I sit there trying to reason with them, I explain the rationale, and I am getting to the point where I think, "hey you came HERE asking ME for help and now you are going pick and choose".

I get the whole loss of control, anxiety, pain, and fear of coming to the ED. I assess for other reasons that a person may not want to don a gown but seriously........I would not go into a business and then pick and choose certain things to downright refuse to do, like refuse to sign paper work at the bank or wait in line. How do you deal with this. I have come to the point where it is beginning to frustrate me. What do you say?

[celticgirl]

BTW, the last person who left my unit AMA, despite my begging her not to, just returned to us 3 days ago on a ventilator and an IABP. I guess you just can't do much if people refuse to let you help them.

Reminds me of something that happened where I work. Not my floor but the cardiac tele floor. A patient wanted to leave the floor to smoke. The nurse told him that since the hospital didnt allow smoking on the grounds, she couldnt allow him to leave. He would have to leave hospital property to smoke. Patient got upset and said he was leaving anyway. She had him sign out AMA. Next thing you hear is a call over the speaker system, "medical emergency" in the hospital lobby. The guy got to the lobby and coded. FULL code.

[cb_rn]

I just remembered this story from my orientation, ahahaha I must have blocked it out. Pts could go outside and smoke with MD order and everyone had the MD order. Newly diagnosed diabetic, just out of the unit due (if I remember right) a DVT. He was a young guy. Diet non compliant, refused insulin, rolled his eyes at teaching...anyway pt and his wife were friendly with me because she and I were both pregnant. Anyway he was gone for a while off the floor and wasn't around to take his insulin. I was busy and the preceptor kept brushing me off about him being gone. So anyway, fast forward to a couple of hours later when I was like..Man, that was a long smoke break. He laughs and says, no I went home for a little while. He drove his car home from the parking lot in his hospital gown, had chinese with his wife and a beer then had her drive him back.

...

you cant make this stuff up.

[PostOpPrincess, BSN, RN]

After having been made a "do not return" at 2 different places for trying to do what seemed intelligent and appropriate I now do the following. I let the patients dictate exactly what is done. And I chart everything. I do a quick education and if patient doesn't want IV or oxygen I just chart -patient declines oxygen after education benefits of treatment explained to patient-

Things have been going smoother for me. Usually the patients do exactly what the doctor wants after they have been in. My life has gotten way easier. In the end, I help the ones that need and want it and the others are there increasing census to boost my job security.

It has been very slow in my part of the country and I welcome all butts on beds, even the ones that don't need to be there.

Bottom line I have to feed my family, so I will kiss everyones butt I need to and after a while it doesn't bother you any more.

I don't look at it as "kissing butt." I look at it as trying to conserve energy.

[PostOpPrincess, BSN, RN]

Reminds me of something that happened where I work. Not my floor but the cardiac tele floor. A patient wanted to leave the floor to smoke. The nurse told him that since the hospital didnt allow smoking on the grounds, she couldnt allow him to leave. He would have to leave hospital property to smoke. Patient got upset and said he was leaving anyway. She had him sign out AMA. Next thing you hear is a call over the speaker system, "medical emergency" in the hospital lobby. The guy got to the lobby and coded. FULL code.

This has happened to me many times.

When it is their time.....it's their time.....

[Fribblet]

I've stopped arguing with my patients. A few I will really try to get at the reason they are refusing care if I think they are seriously in need of care. Otherwise, if you come to the ER expecting a shot of demerol/phenergan, but don't want a work up. I smile, tell the doc the patient doesn't want treatment, go grab the AMA form and hope they sign it.

I work in an adult ER. If you are of sound mind and body and not seriously impaired by drugs or alcohol, you can make your own bad decisions, and, frankly, an AMA form is much less trouble for me than working someone up who doesn't need it in the first place.

Just my two cents.

[LethaChristina]

Bless you guys/gals! Next time a patient is being frustrating--why not try asking them the reason for their refusal? Perhaps it is a "silly" reason to you (like "I just have to maintain some degree of control and individuality--so I don't want to wear the gown, which is both exposing of my personhood, as well as "drafty" in this cold ER")--but then ask them the motivation for the reason (in other words, simply ask them to consider what they are doing--and if there is a better way you could do something--and then explain why you cannot, if you cannot: along with your reason. Dialogue is always a good thing--even in a busy ER... besides you might find yourself being considered "a hell of a nurse" by the very one you thought was so disruptive; and actually cause them to feel respected--motivating change in behavior... both yours and theirs. We NEED each other, don't we? The patients need YOU, and YOU need the patients (since that is how you are managing to stay employed in these disasterous times).

[LethaChristina]

Oh, I wanted to add, since so few patients actually tell the front desk people the actual reason for the ER visit (and often the nurses never really do find out)... dialogue can produce some really wonderful results.

[Fribblet]

... since so few patients actually tell the front desk people the actual reason for the ER visit (and often the nurses never really do find out)...

Where in the world did this notion come from? As an ER nurse, I always know what my patient's complaint is. I've never treated a patient without knowing why they have come to the ER.

[LethaChristina]

Oh, I'm sorry if I offended you--that was never intended. I do know that much of what is "presented" (even seeing on these threads the comments about "frequent fliers", and people with "insignificant" reasons for being in the ER) is simply that: "what is presented as the complaint". Our inability to "listen" because of time constraints, too many patients who are "sicker" or "more critical", as well as "preconceived ideas and assumptions" about each patient (including their behaviors) limits us markedly in our assessments. I am totally sympathetic with the REAL reason for ER's (so transgressed upon with these "minor" situations--who often have no where else to take their concerns--often not able to even access medical care any other way)--so please understand my comments are mostly those of "didactic" nature... I WANT you to continue to be able to do what is most needed--care of the "emergent" situations and conditions.

However, lobbying for more effective ways to treat these "non-emergent" situations (where care does not really happen, except in the simple contact with healthcare providers--which sometimes reinforces "dependency") may be a good action for those interested enough in being "advocates" of a more equitable system of care--and better outcomes for all concerned. Some hospitals have an "urgent care" or some such thing where people can go for these kinds of things... although my experience of this at Group Health Coop in Seattle was less than good--they, too, were only interested in the mechanical processes of lab tests, medicines, or binding up cuts and scrapes.

Seattle at one point had an "open door clinic"--I worked there for awhile as a volunteer... including phone lines for the public to simply talk to trained personnel. It was much less intimidating than calling the Crisis Clinic. When it closed, there seemed to be no other real avenue for this sort of thing (that I am aware) around-the-clock. I also do not know if having the open door clinic reduced visits to ER's in the area--it might be interesting to research.

So many people simply need to be "heard" (not so unlike these thread;)s).

Thanks for "listening"!

[Footballnut]

I'm open. If they can get what they want I will give it to them. Since they(the patient)/we(the taxpayers) are paying for my professional expertise I try to give them enough information to make informed decisions. To cover my bases I have them sign, I document like crazy and I always involve the MD unless the patient has already stomped out.

Another thing I do is to ask if they want my services. "Did you want us to check out whether you are having a heart attack today? If not, that's ok, just sign here please so we can show we offered service and are not liable for anything that may happen to you." It's the same thing for bits of service refused. I use a form for each thing a patient refuses, all informed consents/refusals, of course. I want them to see the issue as their choice, not some sort of reaction to the situation or to the staff. It really is their choice if they are competent adults.

Gowns are nice but I just put a sticky note up for the MD if a patient refuses. I do my best to remind patients that their clothing may get soiled and that the MD can do a better exam for them with a gown on. A few patients don't get a choice but that again is a legal issue.

If a patient is not competent to refuse I press the MD to state it legally so we can proceed with treatment.

The bottom line is that if a patient is competent to refuse my services that is fine with me as long as I have met my obligation of making sure they have informed consent/refusal.