[TeleRNer]

I was discussing with fellow coworkers the unwillingness of patients at my hospital to get with the program: COPDers with pneumonia receiving a breathing treatment followed by a dose of morphine walking to the elevators to go smoke on the balcony. What's with this tolerance of such beligerant actions on the patient's part? Can a hospital have a policy that would state: If you show no willingness to comply with the treatment recommended by your physician, the hospital has a right, the physician has a right, even the NURSE has a right to terminate your stay; a sort of reverse AMA!!!
So what's your take? Is this too harsh a proposal? Totally out of the box, crazy??? Part of me wishes it were a reality...

[TriageRN_34]

The situation that you just described is why there is NO smoking at our hospital typcially (there are a few RARE exceptions for those not in for smoking related probelms and are being tortured/PIA by not smoking...they do have that right...yeah, but I agree...to what end!).

Most of our MD's will not authorize habits for people (like smoking or eating a harmful diet, drinking etoh, drug use, or even noncomplaince in walking or moving...we get lots of those in Ortho....people that WILL NOT get out of bed when they should!) for that reason..hello you are in the hospital! IF they do not comply...AMA is brought up or the fact that you can stay, but your insurance may not cover any of the visit since you are doing things against realistic medical advice! Our MD's also don't like to deal with too much BS because they have many more patients, most of which are compliant!

We also discharge people with paperwork explaining the risks their 'habits' do and the reasons for any orders that contraindicate the habbit and they must sign it in order to leave! That way we are covered if they will not give up that habbit and try to sue!

If you want to be treated, and you have habits that contraindicate that...find a hospital that will allow you to do them regardless and get ready to sign paperwork saying you don't have the right to sue the hospital or staff for your poor choices!

We recently had this big deal about non-compliance and the "puffers" as they call them...the air boots that help against clots that pts have to wear till ambulatory. People kept taking them off despite the orders...now there are rather serious ramifications, including AMA paperwork! Also, if a pt is found not to have them on, a nurse can be in big trouble...so you better make sure they are on!!!!!!!!!! This has become a nightmare of what a patient wants, and what the facility and MD's mandate! I know the seriousness of using these..but what a PIA trying to be the "puffer police" all the darn time!!!!!!!!

This reminds me of what a patient said one day..."if you are going to the hospital you comply with treatments because that is why you are there! I mean, do you go into a kindergarden and start screaming out obsenties for the children because you got the urge or for some reason felt it would help??? Well no...then why go to the hospital and decline things that are in your best interest! Comply within reason, and never forget the goal...get well and go home!!!!".

[phriedomRN]

I totally feel your frustration! I don't think it's harsh at all, but it'll never happen. Of course, I'm also a fan of the "license to reproduce" school of thought

[gitterbug]

Hi Tele,
While I understand your frustration and agree with you on many points, we still have to understand that some people are so caught up in the addiction to nicotine, they just cannot summon the courage or strength to quit. I admire the physician who insists on the nicotine patch, monitoring of activities to prevent smoking, teaching programs, support groups, and even stating no further treatment will be given unless the patient quits. But human nature is what it is, afterall, we do not discharge the obese patient, with elevated BP and BS for having fast food brought in by family. There are many abuses patients partake in, smoking is just one. Where there is free will there is potential for abuse.

[anonymurse]

Originally Posted by TeleRNer

Can a hospital have a policy that would state: If you show no willingness to comply with the treatment recommended by your physician, the hospital has a right, the physician has a right, even the NURSE has a right to terminate your stay; a sort of reverse AMA!!!

If you want to write d/c orders, you can go to med school. Our docs tend to either (a) tell us to let her smoke, or (b) write a scrip for a nicotine patch. Similarly, sometimes you'll see a beer in the Pyxis fridge (the hosp has a license for when the doc orders a beer), and sometimes the doc orders benzos. Her call.

Hi phriedomRN, believe it or not, the "license to reproduce" line of thought was actually put into practice in the US a century or so ago. According to http://en.wikipedia.org/wiki/Compulsory_sterilization :

"The first country to concertedly undertake compulsory sterilization programs for the purpose of eugenics was the United States. The principal targets of the American program were the mentally retarded and the mentally ill, but also targeted under many state laws were the deaf, the blind, the epileptic, and the physically deformed. Native Americans were sterilized against their will in many states, often without their knowledge, while they were in a hospital for some other reason (e.g. after giving birth). Some sterilizations also took place in prisons and other penal institutions, targeting criminality, but they were in the relative minority. In the end, over 65,000 individuals were sterilized in 33 states under state compulsory sterilization programs in the United States."

[RunnerRN]

I work in the ED, and we've used the fact that a patient has gone outside to smoke as a reason to d/c. We are a nonsmoking campus. Usually, this is for people like the "abd pains" who say none of the medications have helped so far. If we find out a person who has received narcotics has gone outside to smoke, has a negative exam, and is just complaining of cont pain, that is enough to warrant a d/c and let someone else into their bed. (Before I get flamed, I'm not talking about those people that are writhing in bed after getting 2 of MS. I'm speaking of the people who are laughing, eating, talking on the phone, and smoking after getting 5-10 of MS)

There isn't much that steams me up more than the pt that comes in c/o CP, gets taken directly back, then proceeds to refuse IV, Os, asa, etc. Why did you come to the ED? I can't treat a possible MI without all of those things. We had a guy come in about 2 months ago who was in CHF, huffing and puffing to breathe, c/o CP. Didn't mind the IV, but kept ripping off his bipap (SpO2 high 80s without, 100% with). I know you feel like you're suffocating when you're on bipap, but even after explaining the alternative (ETT) to this guy, he continued to take it off everytime the RN left.

I'm right there with ya Tele. I think for a lot of people they go into crisis mode when they enter the hospital. Once they start to feel better (and the immediate threat is over) they relax and forget all their "deathbed resolutions."

[canoehead]

I'd love to have a license to reproduce required, but unfortunately once the government comes up with a good idea they have to put it through committees and bung it all up. It was a perfectly good idea, and they wrecked it.

Also, permanent sterilization is really different from making people prove they have sense before they are allowed to reproduce.

[wtbcrna]

Originally Posted by TeleRNer

I was discussing with fellow coworkers the unwillingness of patients at my hospital to get with the program: COPDers with pneumonia receiving a breathing treatment followed by a dose of morphine walking to the elevators to go smoke on the balcony. What's with this tolerance of such beligerant actions on the patient's part? Can a hospital have a policy that would state: If you show no willingness to comply with the treatment recommended by your physician, the hospital has a right, the physician has a right, even the NURSE has a right to terminate your stay; a sort of reverse AMA!!!
So what's your take? Is this too harsh a proposal? Totally out of the box, crazy??? Part of me wishes it were a reality...

As long as lawyers have more say so over healthcare than we do...there will be no ramifications for patients like these.

[phriedomRN]

Originally Posted by canoehead

Also, permanent sterilization is really different from making people prove they have sense before they are allowed to reproduce.

Thank you! I'm not talking about saying certain groups can't have kids. I don't have a problem with MRDD women having a baby, provided they have a good support system and the kid isn't gonna get bounced around from place to place to place. Anyone can have a baby, as long as the child will be taken care of properly!

What I hate to see is a woman coming in to have yet another child she won't have custody of, because she's lost the first 4 r/t abuse or neglect. The addict popping out her 3rd crack baby.

[RNsRWe]

As long as the trend is to call hospital patients "guests" and treat them like "customers", this will never stop. I gather it's getting worse.

I see patients all the time who refuse flowtrons, meds, breathing treatments, dietary restrictions and sometimes plain old hygiene expectations. The idea that people go to a hospital because they are in NEED of medical care that they are obviously unable to provide for themselves is out the window. It has been replaced with the idea that you go to a hospital (after shopping around for the one with the nicest lobby and frills) for someone to bring you snacks and drinks on demand, change your gown and linens after you've been lounging in them all day, and actual medical treatment is optional. Oh, except for the narcs. Keep them comin' baby