Verbally abusive patient, worried I could have handled the situation better

Nurses General Nursing

Published

Let me start out by saying this is a little long winded, but it has been weighing on me and I have to get it off my chest, so bear with me!!!

So, my last shift, I had gotten report on a male patient in his 60s, totally A&O, on our floor for anasarca. PMH of chf, alcohol and IV drug abuse, and hep c (from what I remember.). I work on a busy cardiac unit. This man had been sent to us from the icu on a bumex drip with a foley due to retention, along with a fluid restriction. He had to have assistance to get up, but could make it around just fine with his walker once up. The report I had gotten from the night nurse said he was a jerk, and noncompliant with the fluid restriction of 1000 cc among other things.

So first thing (before I had made it into his room), my charge nurse passes his room and he asks for coffee, she says she has to ask his primary nurse because he is on a fluid restriction. This sets him off, he begins to yell and curse so loudly, I can hear him from 2 rooms down through the closed door. So, then I go to the room. He politely asked for coffee. I politely said back, "ok, let me check the chart and see how much fluid you are at so far because you are on a restriction." This sets him off. He shoves his bedside table towards me, knocking off some of the remnants from his breakfast tray towards me. He begins to curse at me, saying things like "you stupid f***ing nurse" being the primary phrase. So, I calmly say "there is no reason to be this way to me, to be cursing at me. I will come back after you calm down." So I leave and close the door, and he is still cursing. About 5 minutes later, the tech told him that she would have to check with me before she could give him coffee, and he went off again, yelling and cursing so loudly that other patients and families were complaining. So, my charge nurse and I agreed we should call security. He arrives, and handles the situation well. The patient kept saying, over and over, "get me the hell out of here." So, in short, he ripped his tele leads off and began to pull on his IVs and foley. The physician came to the room and spoke with him, saying in short that he was welcome to leave if he did not want to comply with treatment, he could not treat staff that way, etc. so he agreed, yes he wanted to leave. The security officer and the physician said they agreed he should leave. So I removed the two IVs and the foley. While I am doing this, the PHYSICIAN brings him a cup of coffee and a cup of water (roughly 500 cc, he was already around 400 cc so far before this). While I was removing his foley, (he was sitting on the edge of the bed), he threw the cup of water over my head against the wall, but I was soaked. At this point I left the room fuming, and let the officer speak with him. He was saying he now wanted to stay since we gave him his coffee. THIS is the part I am questioning myself about-I told him "no sir, I have already removed everything and you have signed the paper to leave. The cab is on its way to pick you up." He did leave, and had to have assistance from the tech and officer to transfer from a wheelchair to the cab.

I had a hard time leaving some of the things he said to/about me at work that day. (I.e. You fata**, you shouldn't be a nurse, f***ing dumb nurse, I could go on). Remember, this man was as oriented as he could be, and was able to hold a calm conversation with others during this time. Probably some undiagnosed psych issues or something. I have never had anyone speak so poorly about me. So, yes I am glad he left within the first 2 hours of my shift, BUT my conscience keeps hanging on three things: one, that he wasn't able to walk on his own and we just sent him on his way. Two, that the foley was there for retention and it was removed almost immediately before he left. And three, that in the end I kind of told him he had to leave (I think he probably would have anyways).

Thank you if you have read this whole thing, I tried to condense as much as I could! Let me know what you think, if something could have been handled differently, etc.

Specializes in Psych, Corrections, Med-Surg, Ambulatory.
Thank you. In all the comments, you are the first I think that has looked at it this way. I understand he has rights as a patient, but what I'm getting from a lot of the other comments is that I don't have a right to leave the situation when I'm being verbally abused. It's like we are expected to bow down to this kind of behavior and accept it as part of our job-well we shouldn't! If he would have calmed down after a few minutes of being alone after I left the room the first time, this would be a whole different story, but he didn't. He was completely calm when speaking on the phone and to the officer. But me and the physician, pct, and charge nurse? No way. The officer saw that behavior too.

Looking back now, I am glad this patient could not ambulate completely independently, or he might have been coming up to the nurses station doing who knows what.

Actually I think most of us keep in mind what other patients are experiencing and we do think you have the right to step away when you are being subjected to a torrent of abuse. Maybe we didn't do a good job of conveying that, but I think most posters here get that there was no saving this situation.

If I didn't say this before: I don't think anyone could have handled this better.

Specializes in Pediatric Critical Care.
Thank you. In all the comments, you are the first I think that has looked at it this way. I understand he has rights as a patient, but what I'm getting from a lot of the other comments is that I don't have a right to leave the situation when I'm being verbally abused. It's like we are expected to bow down to this kind of behavior and accept it as part of our job-well we shouldn't! If he would have calmed down after a few minutes of being alone after I left the room the first time, this would be a whole different story, but he didn't. He was completely calm when speaking on the phone and to the officer. But me and the physician, pct, and charge nurse? No way. The officer saw that behavior too.

Looking back now, I am glad this patient could not ambulate completely independently, or he might have been coming up to the nurses station doing who knows what.

I've read this entire thread, and I didn't get the sense that the majority of people felt that you had no right to leave the situation. Granted, not many people explicitly addressed it but I think most would agree that you have no obligation to stand there and take that kind of verbal abuse. You did the right thing by saying that you are leaving and will come back after he has had a chance to calm down.

I think even the "I would just give him the coffee" crowd would agree that you don't have any obligation to stand there while he screams profanities at you.

Thank you for your reply. So it is totally acceptable to charted the whole details or it is depending on the hospital policy? If it happened to me, I would prefer to chart the whole events (including his profanities, throwing stuffs to me, etc) in case it gets back to me.

This is a great learning opportunity for me, because it might happen to me someday and that way I know how to handle this. Thanks!

Specializes in Psych, Corrections, Med-Surg, Ambulatory.
Thank you for your reply. So it is totally acceptable to charted the whole details or it is depending on the hospital policy? If it happened to me, I would prefer to chart the whole events (including his profanities, throwing stuffs to me, etc) in case it gets back to me.

This is a great learning opportunity for me, because it might happen to me someday and that way I know how to handle this. Thanks!

You're right. It really is best to chart as much of it as you can and use quotes when necessary. Because this is exactly the kind of person who will complain to the powers that be that he wasn't shown any compassion. And we now know he can be perfectly reasonable when he wants to be, so he can present himself credibly.

Just make sure all your statements are objectively written: what you saw, heard or did.

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
I have read through each one of your comments. I am very thankful for those of you who are supportive in how I handled the situation, and very thankful of the constructive criticism I have received. However, there is one point I don't think I did enough justice to in my original post: that this man had been educated numerous times. It was documented throughout the chart. The physician had even said that she had spoken to him at length the day before while he was still in icu. So yes, he had the right to refuse following the order of the fluid restriction. But when does that make it appropriate to behave like he did? (He was also sitting 100% naked in his room during all of this, his gown went on the floor with the other stuff he threw).

Within the two hours this was going on, the physician, security guard, charge nurse, the tech, and myself witnessed his behavior, along with him saying numerous times "get me the hell out of here." The physician and I agreed that yes, it could have been related to withdrawals, but at that point I don't know if he would have let me give him any Ativan through his IV, as he had already began to pull off the tape to get them out himself.

Also, I think the patients and family were thankful he left as well. They had heard him numerous times overnight yelling and cursing through the walls. The patient next door was an elderly woman who had just been put on inpatient hospice the day before, with a good bit of family in the room with her.

One other thing: where I work, the physicians normally do not put in an actual "discharge order" for pts leaving ama. The pt signs the Ama paper (or refuses to), then leaves, and we document.

Looking back on this, I think this guy was at the end of his "sober period" of being in the hospital, and probably needed a fix of whatever drug of his choice.

Let me make this clear as well:

I think giving him the coffee, fluid restriction or not, would have solved the immediate problem, but not the problem that would have inevitably arisen 20 min later.

I agree with you. You did the right thing.

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
There's this really great article called "care goes in, crap goes out". Worth a read. Basically the patient is the centre. Nurses, doctors, family, friends are all in outer circles and the patient is allowed to dumb their crap out to their support.

I get it. It gets hard sometimes. Especially when their non compliant and disrespectful. But nobody WANTS to be in hospital. Maybe he's like it all the time. Or maybe you're meeting him on the worst days of his life and he's filled with nothing but fear. You're gonna get crap dumped on you, so it's important you have your own support that you can share that with. Maybe a little more teamwork and education. Some people might disagree with me, say there's no excuse for certain behaviours but I just don't believe patients you meet in hospital are a true representation of themselves usually. And for every awful one, you'll get one who is sorry they're "wasting" bed space. You just gotta hope the balance is there.

Hospitalized people are still pretty much the same person they are outside the hospital. The verbally and physically abusive ones don't miraculously become kind, gentle folks just because they're discharged. I don't believe this "you're meeting him on the worst day of his life" crap. He's a donkey behaving like a donkey.

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
Nope. You cannot say what he understood. You can only say what you did and what he did, using patient-centred language: "Pt was provided with extensive and repeated teaching re necessity of fluid restriction. At 0800 was given coffee at his insistence."

Or even better: Patient was re-educationed re: fluid restriction. As he is already 250cc over his fluid restriction, coffee was not given and patient education re: fluid restriction reiterated."

You were in a no-win situation. Who is to say if you gave him the coffee he wouldn't be pulling the same thing half an hour later? There are sick patients who want to get well, better that they have the bed.

Specializes in ER.
Any patient has the right to refuse a doctor's prescribed treatment. YOU had no right to refuse the patient's request. It's a hospital, not a jail.

This is not about you, it's about the patient. You basically bounced out a patient that was not ready to go home, that even rescinded his own discharge and was visibly too weak to manage his own care... because your feelings were hurt.

Disagree.

if the patient wanted a rope to hang himself with, would I provide it after discussing the pros and cons?

Giving fluids over the limit would have exacerbated his condition. I would do the education piece, especially ways to make a little fluid go a long way, and told him he makes his own decisions. I'd get the coffee up to his fluid limit, then start using ice chips for the last 50cc. I won't be involved in a decision that will hurt him. He's free to get up and get the coffee himself, have relatives bring something in, or call for delivery. I don't interfere, but I'm not helping him go against doctors orders.

He wanted to leave AMA when he couldn't demand and receive, fine. I'll remove medical equipment, call the doctor, and the patient can dress himself and take himself down to the cab. (That approach has kept a few confused patients in my ER long enough for meds to kick in) If he's too weak to move, I guess he's stuck (and not safe to go home alone anyway.) Again, he can problem solve his way out by calling for outside assistance, and doing that will show he can care for himself, so chart carefully. Yelling and cursing would indicate an inability mentally, to work things out. Don't approach him as an adversary, be a person that wants to help, but refuse to assist in a bad decision. Keep going over options that might make the stay tolerable, and put the responsibility for physical action on him.

In this situation, our house supervisor issued a cab voucher to take him to the address he provided. Under normal circumstances we absolutely will not provide a voucher for those leaving AMA-but he would have had no way to get anywhere but our curb in front of the hospital. So that was our one kind act towards this guy I guess.

Specializes in Pediatric Critical Care.
There's this really great article called "care goes in, crap goes out". Worth a read. Basically the patient is the centre. Nurses, doctors, family, friends are all in outer circles and the patient is allowed to dumb their crap out to their support.

Ok, first of all that concept doesn't mean you get to dump all over the people in the outer circles and treat them poorly. It's just who is crying on whose shoulder.

I buy that concept for like, if you friend's parent dies. When someone dies, you support the people who are in the circles closer to the center than you (spouse, kids, etc. being the center circle). You avoid asking people in the inner circles to use their energy to support you during the time of grieving, and you are in turn supported by the people in circles further out than your own.

I don't find this at all applicable to the nurse-patient relationship, anyway. That is a professional relationship, not a personal one.

Hospitalized people are still pretty much the same person they are outside the hospital. The verbally and physically abusive ones don't miraculously become kind, gentle folks just because they're discharged. I don't believe this "you're meeting him on the worst day of his life" crap. He's a donkey behaving like a donkey.

I'm glad someone rebutted the "worst day of his life" thing.

I just have not found it to be true, as far as being an excuse for poor or abusive behavior. That is to say that many, many people are stressed when we are caring for them (or their loved ones), but the worst that most people do is perhaps give a "short" answer, or become flustered or a little anxious or mildly over-bearing with their requests or their mannerisms - - and then a lot of them apologize because they themselves perceive that their interactions are stressed and different than what is normal for them! These are the majority of people. They are not screaming profanities and throwing things when they become stressed.

For people who do not regularly scream profanities and throw things, doing so would be about the last thing to come to mind when stressed.

Those who do such things when stressed/ill/hospitalized already believe that those are acceptable ways to behave on a day-to-day basis.

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