[sticknurse]

Hello everyone, I am working with a challenging young man who suffered a spinal cord injury. He is 27 and preferes to sit up in his wheelchair for hours at a time despite our admonishments. I am looking for advice because he's refusing interventions and education attempts we've made so far. I am trying to find a way to impress upon him the risks he's taking and help him understand his risk. We also suspect ( I work in the home with another nurse) that he may be abusing his prescription valium as well. He is a recovering addict by his own admission and sometimes apprears to be "under the influence" of something when he is assessed. He also refuses vitals and asks us "don't write that I refused vitals." A nurse who works with him told me recently he threatened to fire her if she reported a new area of pressure she noted to the doctor. He basically told her if she called the doctor she need not return. What do you do with a patient like this? There's virtually no family support in place, his own mom stated "I don't want to be his back-up caregiver anymore, I've had it with his verbal abuse and manipulative behavior." (Mom is a social worker!) What would a prudent nurse do?

[kizzykatlove]

i wouldn't want to be his nurse either. but i would do what i had to do to cover myself legally. if he didn't want me back.. so be it... it is his right to refuse any treatment , but .. cover yourself.. if he ever goes septic from those wounds, you want to be have your bum covered.

[sticknurse]

I am providing him with educational material which will explain his risks, and charting all the responses I get when I attempt to enlighten him. He's very intelligent, but stubborn as well. We are concerned that one of his wounds is infected now and he's refusing to go to the doctor so far. I've never taken care of a more challenging patient....thanks for the advice!

[kukukajoo]

Time for a psych assessment if you ask me. If he is being noncomplaint, combattive and manipulative.... and possibly abusing meds I would definately refer him for one no matter what it is he wants himself!

[fultzymom]

In a case of a non-compliant patient, I always make sure to document every thing that happens. And you have to report everything to the doc, even if he requests that you never come back again. Is he going through some psych issues that need to be dealt with? It must be hard to be so young and find yourself in that kind of situation. Maybe he needs to see a therapist for someone in the Mental Health Profession.

[Nazarite]

If his own mother who is a social worker has established her boundaries and refuses to deal with him, then he is definitely in trouble...
If he says he is in recovery but is suspected of abusing his Valiums and you or someone knows or can verify it because he comes up short every month on his pill count, etc..., someone (don't know who) should confront him and tell him he's full of crap and in relapse (does he have a sponsor or any 12 step friends?)......sorry but i have prior experience with all of this and coddling and telling people in recovery what they want to hear rather than what they need to hear is a form of enabling.......and using under the guise of 'it's a dr.'s prescription' is a line that is an old rationalization used by addicts for ions...

I took care of a patient years ago who was 32 years old when I came to care for him with severe type 1 diabetes, he was partially blind and had severe neuropathy when I first took care of him....basically acted like your fellow, except in a nicer manner, thank God...but myself, the agency, his mom, etc couldn't force him to do anything....well by the time he died at age 35 he had a heart attack, was on peritoneal dialysis, lost both legs, (in that order) and basically died in what i would term "suicide by noncompliance".....it was a shame too because he really was a sweetheart....he just couldn't get past all his losses, dwelt on them, and no matter what interventions were attempted continued to be non compliant....i guess his attitude was i'm going to do what i want to do and enjoy what i can, but unfortunately it was at his own detriment......i always have to wonder how much longer or better things could have been had he been compliant....but i'll never know...to quote frank sinatra, he did it his way.....
sad, but bottom line...it was his right....
i hope someone can get through and intervene with your patient before it is too late.....
you know that tv show "Intervention" on A&E? well the disabled are not exempt from that...maybe a group of family/friends/caregivers/people he may know in recovery could stage one....don't know if an addictions counselor is available but it could be a starting point....addicts need to be confronted.....
hope this helps, and tell him someone is praying for him

[caliotter3]

Same as the others have said, document everything. But do not follow his instructions to leave out refusals and to not call the doctor. Document his refusals. Call the doctor as you would for any patient. If he fires you, then that is what happens. I have seen this type of patient who refuses the world, then when they get the idea, they sue everyone involved for their care because of their poor condition, that was brought upon by their own noncompliance. You have to be mindful of your license. And if he is suspected of abusing his controlled substances, then how is he doing it? Doesn't your agency use an accountability record? He needs to be spoken to by the Director of Clinical Services regarding his eligibility for future care. All the contracts that I have seen state that a client may be discharged from services for reasons such as you describe.

[Blackcat99]

When I worked at a LTC there was a non-compliant lady who had a decubitus ulcer. After her death, her family sued the LTC facility and won their case. Apparently, the nurses had not done enough documentation about her refusal of decubitus care.

[RN1121]

If he is made aware of the ramifications of his actions and still insists upon doing what he pleases, that's on him.

If you and other caregivers have documented his non-compliance and disinterest in his plan of care, then you have covered yourself from his ignorance.

I've always thought that people will do what they want to do when they want to do it.....similar to smoking and losing weight, I guess.....
If your not ready to take responsibility for the decisions you make, then be ready to handle the consequences, at any cost...

Your a nurse, not Superman! He is making his own informed decisions, and he has every right to do so...

Just know you can't change anyone who doesn't want to change....

[nightmare]

This guy is obviously in denial and probably depressed.He cannot feel the pain so it is not there.He's probably given up on life and doesn't care any more.(Well that's just a thought anyway)