The Dirtiest Word in Chronic Health Care - page 3

by rn/writer Guide

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The Dirtiest Word in Chronic Health Care Our treatment of patients with chronic health conditions often looks more like a wrestling match than a collaboration. But what are we supposed to do with cardiac and renal patients... Read More


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    My brother-in-law chose not to do his insulin for the past few months. Showed up on our doorstep 6 weeks ago with a foot infection for me to "fix" since I'm a nurse. 12 days in the hospital, 2 surgeries to remove all his toes, and then he moved in with us for awhile. He can't go home until he can go up stairs and take care of himself. At first I was emptying his urinal and waking up at 8:00 each morning (after working swing shift) to fix his breakfast. When I didn't get up, he fixed his own breakfast, slipped, bonked his foot and bled all over my floor. He's slowly healing and now sort of walking, but I've spent countless hours helping him over the past few weeks. All because of his noncompliance... oh, excuse me, his choices.

    He is now checking his blood sugar and taking his insulin and mostly making good food choices. Thank goodness for that. Please excuse my grumpiness. I need a bit of rest.
    I'm so sorry you're going through this. My article was talking about newly diagnosed diabetics who are at a fork in the road. They can either perceive healthcare workers as the enemy and meds and diet and the rest as intrusions to be avoided or they can see us as allies and the meds and diet and the rest as tools to fight the disease. My point was that we have a lot to do with which view the patient takes.

    If we jump in and start rescuing before the patient sees the need for and the importance of the measures that can help him, we stand a good chance of "vaccinating" the patient against ever taking us seriously. Then it takes something like losing part of a foot to cut through the denial. I don't know that this happened with your bil, but the immediate imposition of a bunch of rules and restrictions is so common that it may well have been a part of his experience.


    Yes a morning pill ... i worked as Nurse in charge in a NH few years ago and i had some of the patients on Dr's order for 1 pill every day at 6 am . sticks , diet , insulin and all others being observed troughtout the day but I gave that 1PILL at 6 am per DR Order !
    Maybe it wasn't the med itself, but the fact that it was ordered for 0600. Nursing homes are just that--the patient's home. The fact that the doc ordered the pill for 0600 may work for him and for you, but it may feel intrusive and rude to a sleeping patient. That's when you talk to them and find out why they're resisting. Maybe that same pill would be welcomed at 0800.
    Last edit by rn/writer on Dec 3, '11
    talaxandra likes this.
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    Quote from yrmajesty3
    OK...I see your points. We don't want to come off in a demeaning or patriarchal way towards our clients/patients. <snip> what other word-smithing shall we use? It seems to me that politically correct wording doesn't help anyone get better.
    The reason I don't use 'compliant' and 'non-compliant' isn't because I "don't want to come off in a demeaning or patriarchal" or because I think it's politically correct, or as a form of word smithing. I believe the words we use often carry a potent, and unexplored, load of information. As rn/writer wrote, "non-compliant" reveals subtext about an adversarial relationship rather than a partnership, opposing goals (getting the patient to 'comply' rather than working out to incorporate techniques of diabetes management into the patient's life), and predicts failure.

    Rather than using 'non-compliant' in my notes I document the conversation I've had with the patient about what aspects of their management plan didn't work and why, what might be more effective next time, support techniques (referral to the dietician, for example) etc. And if the admission's still acute I'll document that this is not the most appropriate or effective time for this discussion, but that I'll reassess the next day - and ask in the interim that other staff refrain from chiding the patient or attempting discussions about management plans unless initiated by the patient.

    talaxandra - endocrine CNS
    rn/writer likes this.
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    Thank you so much for you insights, Talaxandra. This is a population that is routinely disrespected and diminished by the medical community. But if a non-diabetic were one day told that they had to change their diet and many other aspects of their lives--right now!--they might find themselves balking.

    Diabetic self care is not an all or nothing proposition. Something is better than nothing. And if that "something" goes well and proves doable, something else might be added. The patient will demonstrate a ramping up rather than the ramping down that frequently takes place as one thing after another is decreased or let go entirely.

    The "ally vs. adversary" comparison is one that a lot of healthcare workers don't get. We say we're fighting the disease, but we end up fighting the patients. And they fight back. It makes such a difference to come in as an ally and say, "Here's the problem. Here are the remedies. How can I help you be successful in your fight?"
    xtxrn likes this.
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    Quote from beachmom
    My brother-in-law chose not to do his insulin for the past few months <snip> He's slowly healing and now sort of walking, but I've spent countless hours helping him over the past few weeks. All because of his noncompliance... oh, excuse me, his choices.

    He is now checking his blood sugar and taking his insulin and mostly making good food choices. Thank goodness for that. Please excuse my grumpiness. I need a bit of rest.
    Hi beachmom - one of the most unfair things about poorly-managed diabetes is the toll is takes on people around the patient. If it were my BIL I'm sure that as well as being tired I've be angry that I was being inconvenienced as a result of his poor long-term decision making.

    Obviously I don't know your BIL, and he may be an inconsiderate PITA in many respects. But if he's anything like most people with diabetes, particularly if he was diagnosed some time ago, his diabetes education consisted predominantly of rules, threats, one way communication and an expectation that he modify virtually every aspect of his life.

    We all know that diabetic complications are the result of long-term glycemic imbalance, and that the only uncertainty is which system will be affected first, and how badly: impotence or gastopares, diminished vision or blindness, lose renal function or lose a toe? But these are long term - many of my patients feel fine. They may eat a chocolate bar, and find that though their blood sugar shoots up, they feel okay - maybe they need more insulin, but big whoop. Or they skip a pill and nothing happens. And over time the compromises of effective diabetes management give way to short term preferences.

    We all do it - I want to lose weight, but I have a slice of cake. I want to improve my cardiovascular fitness but right now I'd rather surf AN than go outside. I should... but I want...

    Making lasting change is really difficult. It's hard enough when the person's motivated - by a desire to be thinner, or fitter, or not have symptoms of IBS. I'm thinking of a friend transitioning to a FODMAP diet with mixed success, even though the consequences of eating the wrong foods are rapid and painful. How much harder when the results are distant and the intervening time's unaffected.

    Any movement toward good glycemic control is better than none. Any exercise is better than none, any medication, any monitoring... And small changes are not only more sustainable, they lead to further change. SO working on a collaborative plan and reviewing it regularly has significantly more success in the long term. And that's what we care about.
    rn/writer likes this.
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    Friends, I'm afraid I am not a "compliant" diabetic patient at all times, although my lab work is pretty good. For me, the fundamental problem is that I only have so much emotional and intellectual energy. I have a stressful job, a tight personal and work schedule, an adult child with serious and unpredictable health issues, and a family with a lot of other needs. On top of that, I have a good deal of arthritis foot pain, which limits my activity, but which does not seem to interest my physician at all.

    So, I do the best I can. I did some diabetes counseling with a program set up by my insurance company and dropped out. It was mostly canned motivation, and I had to miss work to attend the sessions.

    Here's what I'd like: someone to say, "Gosh, honey, considering what you are dealing with, you're doing great! Here are some suggestions I'd like to tell you about..." And then come up with something practical.
    talaxandra likes this.
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    I am a nurse with a "chronic illness" And after being dx with MS,I have become a better nurse(emotionally and emphatically) Put yourself in that pts. shoes. Period. Its not hard. Its called EMPATHY. And guess what,Ive become more non-compliant everytime I leave my neurologists office. Just sayin. This article is brilliant and I get it. Walk a mile in my shoes,than tell me,when I was doing everything I Was supposed to do to feel better,eat right,exercise,ect.....That I shouldnt be feeling as bad as I do. Thats when I starting becoming non-compliant.
    NDXUFan, xtxrn, talaxandra, and 1 other like this.
  7. 0
    Quote from julieanneb
    I am a nurse with a "chronic illness" And after being dx with MS,I have become a better nurse(emotionally and emphatically) Put yourself in that pts. shoes. Period. Its not hard. Its called EMPATHY. And guess what,Ive become more non-compliant everytime I leave my neurologists office. Just sayin. This article is brilliant and I get it. Walk a mile in my shoes,than tell me,when I was doing everything I Was supposed to do to feel better,eat right,exercise,ect.....That I shouldnt be feeling as bad as I do. Thats when I starting becoming non-compliant.
    Very well said!
  8. 0
    Quote from CrazierThanYou
    Very well said!
    Thank u!!!!!!!!!!!!!!!!!!!!!!!!!!!
  9. 0
    Quote from beachmom
    My brother-in-law chose not to do his insulin for the past few months. Showed up on our doorstep 6 weeks ago with a foot infection for me to "fix" since I'm a nurse. 12 days in the hospital, 2 surgeries to remove all his toes, and then he moved in with us for awhile. He can't go home until he can go up stairs and take care of himself. At first I was emptying his urinal and waking up at 8:00 each morning (after working swing shift) to fix his breakfast. When I didn't get up, he fixed his own breakfast, slipped, bonked his foot and bled all over my floor. He's slowly healing and now sort of walking, but I've spent countless hours helping him over the past few weeks. All because of his noncompliance... oh, excuse me, his choices.

    He is now checking his blood sugar and taking his insulin and mostly making good food choices. Thank goodness for that. Please excuse my grumpiness. I need a bit of rest.

    You said it well , " All because of his noncompliance" but for the sake of this thread i guess we should say because of " his choices" . I have a question not for you but for those not in favor of " the dirtiest word"
    *Now that he understood what was being asked of him and decided to follow on that ..will it be him making new choices? or complying with his diabetic care plan ?
  10. 0
    Maybe it wasn't the med itself, but the fact that it was ordered for 0600. Nursing homes are just that--the patient' home. The fact that the doc ordered the pill for 0600 may work for him and for you, but it may feel intrusive and rude to a sleeping patient. That's when you talk to them and find out why they're resisting. Maybe that same pill would be welcomed at 0800.[/quote]



    Yes you are saying the same thing i did but in a different way . I was saying i wouldn't chart "non compliant " on a pt who resting taking their 6 am pill b/c i takes time before coming to such conclusion .taking into consideration what you have just mentioned i often did the 1hr before or 1 hr after when passing meds if time appeared to be the problem . So bringing this i.e in my text was to simply show that as Nurses we know .... when a pt is being compliant vs non compliant; base on observation and regular interaction .it usually not an outcome of one nurse experience with the particular pt on one occasion that lead to conclude but often in my experience it was a result of multiple nurses and /or others care givers with one resident refusing care before the word was even considered & used in the chart .


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