NONCOMPLIANCE, why be at the big H? in the first place?

[CaLLaCoDe]

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...

[RunnerRN, BSN, RN]

Take, for instance, the pt refusing to wear O2 or BiPap. As long as you inform them, inform the doc, and document, then I think that's their choice. There may be other aspects of their treatment that they accept, such as neb treatments and antibiotic therapy.

Yes, they might be an annoying smoker or another type of social outcast with an addiction on top of it. I figure, it's not my problem, it's theirs.

Here's my issue with just letting the pt remove their bipap (when he was obviously huffing and puffing, had a poor sat without it, and had to breathe between every 2 words): poor oxygenation and dyspnea make people feel panicked. Add a bipap on top of that which makes you feel suffocated, and claustrophobic. No, of course you can't glue the mask to his face, but you have to take into account the other factors. We kept telling him to give the Lasix some time to work, because I think once we got some fluid off his lungs he would breathe easier. We also pushed some Ativan in hopes it would calm him down.

While smoking/overeating/etc may not be my problem, I feel like it is pretty telling when someone comes in c/o "I can't breathe" is barely hanging on with a NRB, and wants to know if he can go outside to smoke. Ummmm no. I use pt's ability to walk self outside to hide in the bushes and smoke (we have a nonsmoking campus) as part of my assessment.

The bipap pt I'm referring to above was in his mid-40s, approx 300 lbs, had been smoking since his teens, dx COPD/CHF/DM late-30s, and had not changed a single poor habit. I understand your point regarding being patient and nonjudgmental, but it is very frustrating when my education goes in one ear and out the other. The hospital is not a hotel (contrary to popular belief today) and I just don't get why someone takes all the time to come in, and ignore EVERY RECOMMENDATION we give them.

[Elvish, BSN, DNP, RN, NP]

This may be a bit OT, or maybe not. To me it depends on the pt's age/severity of her illness. If my pt is 80, diabetic, eats like crap & doesn't want to check her sugar, I really don't care. Is it really a good use of my time to get in her face & preach? Nah. A 45-yo, OTOH, who eats crap, smokes, & has an A1C of 12, well, that bugs me. Do I say anything to the younger person? Depends. Some people don't do what they're supposed to but keep coming to the hospital/clinic because they desperately want someone to call them on the carpet & offer them some help.

The story is, in my mind, different c each patient. I have a 15yo cousin who has had a seizure d/o for 14 years now, some days the sz are intractable. She is getting close to the end and what she really wants more than anything is a Wendy's Frosty. Let her have 10 every day if that's what will make her happy, seriously.

I am of the license to reproduce camp too. You have to have a license to hunt, drive, and fish, but any people with the right parts can create a human being that they have no intent of ever caring for. (Like the crack addict I cared for who had had babies 1-4 taken away from her...and went on to have 5, 6, and 7.) That is just wrong.

I for one do not do all I am supposed to do. Just this week my doc read me the riot act for not doing my BSE, even though I am an OB/GYN nurse and am forever teaching my patients how to do it.

[nurse_nan]

It's called patient's rights and responsibilities. They seem to forget there is a second part to that phrase. We point out to them that they have those responsibilities and they have freedom of choice. But if their freedom of choice clashes with the best treatment plan for them, then they are invited to exercise their freedom of choice elsewhere.

I too am a fan of license to reproduce.

I am also a believer in theories such as survival of the fittest and natural selection.

[tvccrn, ASN, RN]

Arwen brings up a point, if the patient is, for whatever reason, near the end of live I see no reason to push treatment on them. Let them enjoy what time they have left.

BUT, if they aren't and the have been taught and taught and taught, yet are still doing the very things that cause their problem, I don't want to see them. Yes, they have the right to decline treatment (not a big fan of saying refused treatment), but if they are doing so, don't bother to come in.

You do have the right to kill yourself slowly by not following medical advice, but don't take up the valuable time that I can use to treat the patients that really want the help.

If you really need to smoke that badly, stay at home and do it there.

tvccrn

[CaLLaCoDe, BSN, RN]

[mouse]

If my pt is 80, diabetic, eats like crap & doesn't want to check her sugar, I really don't care. Is it really a good use of my time to get in her face & preach? Nah. A 45-yo, OTOH, who eats crap, smokes, & has an A1C of 12, well, that bugs me.

[/mouse]

I totally agree, lifestyle choices made by an elder are probably so ingrown, like a toenail LOL that the idea of convincing them to change is futile. And, I would like to add that this to me involves the aspect of respecting my elders...too often we in this field don't...by stating "Grandma, or Grandpa, or Hun" and not their name when addressing them and taking away their dignity.

[Elvish, BSN, DNP, RN, NP]

If you really need to smoke that badly, stay at home and do it there.

tvccrn

Amen to that.

What really gets my goat is the women in preterm labor who are on bedrest (that's a joke) who go downstairs 7 times a day to smoke & wonder why they're still contracting.

[NicoleRN07, RN]

I work in the ED, and I feel that if you are well enough to smoke, then you are well enough to go home!! That goes for on the floors as well.

[blueheaven]

The facility that I work at has a smoking area for patients. I have ALWAYS been of the mind-set that "if you can put on your robe, push your IV pole and trudge your butt out in freezing temps to the smoking area...you don't need to be here!" Then the lungers that come back in wheezing and say they need a treatment! ARRGH!

[DutchgirlRN, ASN, RN]

At the HH company that I work for, we discharge for non-compliance. We feel as though if harm comes to the patient due to their non-compliance, and we were aware of it, then we may be held liable in some way. The risk is too great for the agency. I wonder why insurance companies continue to pay for repeat hospitalizations due to non-compliance. i.e. COPD exacerbation. If they audited the chart and saw that the pt was going out to smoke....HELLO! it seems to me it's kinda like they're defrauding the insurance company. No wonder our healthcare is so outrageously high!