How would you handle this patient.

psalm, RN · Feb 10, 2006

...don't sweat it, Friend! You did all you could. I would document in the nursing notes of this pt. chart about the c/o pain at 15, and all you did to help, and also document the screaming at you about being sued by pt. and his wife. The squeaky wheel gets the grease.

...in the future, with a pt. like this, set limits. I tell my squeaky wheels (like yours above who can move to the vending machines or go for a smoke but are in such pain) that we will try non-pharm ways first, to aid with the PCA he is getting already...lights low, volume low, stimulation and stress low, position change, warmth,close eyes, limit or stop with caffeine drinks, etc. and I will check him after I see my OTHER pts. If he threatens to go AMA remind him that is his decision, but he can't take the PCA with him, and sometimes you have to feel worse temporarily before feeling better.

...some ppl just know how to work the system and it is a game with them. Don't feel badly. Be kind but firm.

CrunchRN, ADN, RN · Feb 10, 2006

Sometimes everything you do will never be enough. You just have to accept it and do your best which it sounds like you did. Some people will never feel satisfied no matter what.

GooeyRN, ADN, BSN, CNA, LPN, RN · Feb 10, 2006

Im sorry you had a night like that. Some people are never happy. Yes, he was in pain. You called the doc to up his pca. you called about a sleeper and called the pharmacist about it. It just wasn't safe. You offered non pharm. options. He refused. He was walking around to get snacks and what not. He threatened to leave AMA. Was he really in that much pain I wonder if he was walking and willing to leave with no pain meds? If I were in that much pain I don't think I would want to leave without pain meds! You did what you could. The wife is just mad b/c you couldn't help take his pain away. But you did everything you could have. I hate nights like that!!!!! I hope that you don't have another night like that for a long time!!!

DidiRN · Feb 10, 2006

When I get someone like this, I document, document, document. I will document exactly what they say, and exactly what they did (especially the part about getting up, and also the threats of leaving AMA, the recommendation about pharmacy not feeling comfortable giving him a sleeper, etc.), and what I did for them in great detail. Even the threats they make, just document exactly what they say. If a lawyer reads it, then they will get a very clear picture of what this person is like. Be careful though, you don't want to make judgements on the charting, instead of just saying patient is demanding, go into specifics about what he has said and done.

I'm sorry too you had to go through this.

I'm a fairly new resource RN, I graduated in May 2005. I was working on a Medical/Oncology Floor last night 11-7 that was pretty busy. I had this patient who had knee surgery and left AMA a week ago, because he is a very noncompliant diabetic and the staff wanted him to take sliding scale insulin, but now was back because of knee pain. He was rating his pain a 15 when I came on so I called the pain specialist consult he had and got an order to increase his PCA. The pt had also wanted his sleeping med ordered so I talked to this Dr. about that but he didn't feel comfortable ordering it. So I immediately turned up the PCA dose. Then the pt kept going on and on about if I couldn't get this sleeper he was going to leave AMA, so I called his admitting physician who was upset with the pt to begin with after leaving AMA a week ago, and gave me the order if the dosage was ok with pharmacy. So then I called pharmacy who did not approve the dosage. This is getting to be like 2:00 in the morning and I have barely seen my other pts or started anything else I am supposed to do. So I went in and talked to him and he agreed to stay until morning basically saying he was going to yell at the doctor and leave. I offered him ice which he refused because he gets chilled and did everything I could think of to lower his pain. I got him food and anything he could need. This pt had no problem getting up and fairly quickly walk to the pop machine, but his pain was just horrible. Then what topped it off I heard him tell the aide working with me and his wife that I lied about turning up the PCA and was talking down to him. When I went to clear his PCA pump in the AM, I showed him how it was increased and what dosages he was receiving. His wife and him ended up screaming at me saying they were suing me as well as the hospital. I was mad, I had tried everything possible to make this pt comfortable, called dr's in the middle of the night. I also felt like I couldnt give my other pts as good of care because I had been so busy dealing with this pt. How in the world are you supposed to deal with a pt. like this. Sorry this got long. I was just frustrated.

Daytonite, BSN, RN · Feb 11, 2006

How in the world are you supposed to deal with a pt. like this. Sorry this got long. I was just frustrated.

Smile. Go on about your work. Realize that this patient has a lot of issues, none of which you are going to be able to solve. He created much of the hell he is in, and he has to deal with it. As long as you are respectful, kind, did the best you could and followed good nursing practice you will never go wrong. Threatening a lawsuit is just his childish way of trying to get one up on you. Try to put this behind you. If I had been you and having a bad day I would have found a tactful way to help him go AMA. (I know, I'm bad. But it's nice to dream about it, isn't it?)

clee1 · Feb 11, 2006

Document, document, document..... then tell the pt to be sure to spell your name correctly in the lawsuit. :devil:

Town & Country · Feb 11, 2006

Where was your charge nurse when all this was going on?

The charge nurse should have stepped in and handled this patient after you'd exhausted yourself and your resources.

mjscan_07 · Feb 11, 2006

At our hospital we do team nursing and basically the only thing the person that is designated charge does is to assign which rooms get the admissions. Our House Supervisor did talk to this guy about his sleeping med he was so upset about becasue she was the one who had to call pharmacy, but he was nice to her and told her he would leave AMA in the morning.

Daytonite, BSN, RN · Feb 12, 2006

Please, please, don't feel like you've done anything wrong. This guy is manipulative and getting sucked into the little games that he is playing is not going to help you. He's manipulative and pulling out all his big guns to use you. He talked about you (particularly to others) hoping the information would get back to you so that maybe it might cause you to take pity on him and get him what he wanted. It didn't work and he's angry, mostly at himself that he failed. Let it go. This is not your fault. You did exactly what you, his nurse, should have done. Believe me, he knows the game better than you. He's just frustrated that he can't get his way. Somebody had to be his scapegoat and today, it's you. Honestly, he's not worth all this worry. I've had plenty of patients like this myself (I worked on a unit that had detox beds) and this is very typical. They often will pick one or two people on the staff to be their "bad guys". They do this hoping that the person they are badmouthing you to will do what he wants so that (1) he'll be nicer to them, and (2) he won't talk about them the same way. Of course he was nice to your supervisor. It was because he was able to get something out of her that he wanted, or at least that's what he thinks. It's all a manipulation game he is playing, that's all. Next admission, you may be his "angel" and the same supervisor will be the bad guy. That's how manipulators operate. Forget about him. He's just one of the aggravations of the profession that come our way. Saying he's going to go AMA is just another manipulative ploy on their part as well. He's hoping that someone will try and talk him out of it (because that's what happened before when he's pulled this) and help him get what he wants. He's stuck in your hospital because he has no other outside resources for drugs. He's taking advantage of his knee pain to get more medication. He wasn't about to leave until he was very sure that he had tried every little trick in his book to get more pain medication. Even if he truly has a post-op knee problem going on, it really isn't his focus. Just think about this. . .normally, someone in his predicament would be carrying on and worried about something being wrong with the knee surgery, wouldn't they? Look what his focus is: pain pills and sleeping pills.

grinnurse, RN · Feb 13, 2006

At our hospital we do team nursing and basically the only thing the person that is designated charge does is to assign which rooms get the admissions. Our House Supervisor did talk to this guy about his sleeping med he was so upset about becasue she was the one who had to call pharmacy, but he was nice to her and told her he would leave AMA in the morning.

With that kind of patient I would have found a polite way to tell him not let the door hit him in the orifice on the way out!! Most of the pts that I have had leave AMA didn't really need to be in the hospital in the first place!! I have little if any patience for these pts. b/c like you said they truly take away from the other pts who really are sick and need your attention. Probably not the best attitude to have but this how I feel about them.