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

[NurseMom2016]

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.

[TriciaJ, RN]

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.

I would have paid for his cab fare myself.

[martymoose, BSN, RN]

not sure why you are taking this personally.

Buh bye, dont let the door hit you.

I fail to understand why these people come into the hospital in the first place. I absolutely sympathise that it must really really suck to not be able to drink when you want to( id say its more like torture).But if you come in, an ddont want to comply with what the doc says needs to be done, then you should have a palliative consult, and drink all the water you want.

I absolutely hate being the fluid police, but we get yelled at by the docs for not "enforcing " their orders.

A 1 liter fluid restriction is the pits. Thats why I dont take it personally when pt goes off on me about it.

[guest52816]

Yes, a liter fluid restriction does suck. But so does fluid overload when you have CHF.

Personally, I would like to see more physicians fire patients who are non-compliant. For example, patients who are admitted to the hospital for COPD, who then leave the unit to smoke. Why bother coming to the hospital?

Some physicians do refuse to care for these patients, and that is a step in the right direction.

Healthcare resources are limited and shouldn't be wasted.

[BSNbeauty, BSN, RN]

I would educate and advise a friend to bring him coffee. I would not bring him coffee, especially acting like that.

[EJwilson]

I don't think you could have done any more than you did. First of all, while he's a patient in your care, which you are providing under doctors orders, giving him the coffee would have made you culpable if he then experienced a CHF exacerbation. If the patient is belligerent, verbally abusive, and willingly non compliant with his care, it is not your responsibility to 1. Put your job on the line by disobeying orders that have a clear medical purpose and 2. No professional- no- no human being should be expected to suffer physical and verbal abuse just to perform their job duties.

Sure, you are a compassionate nurse who cares about patients, but you also have to protect your dignity, health, and license.

You cannot save the world, my friend. Just do the best you can while respecting and protecting yourself.... that's all we can do in such situations. I urge you not to ruminate over this any more!

[Munch]

Where I work we would get our behinds handed to us if we would have given him the coffee when he wasnt able to have it. The people saying they would just give to him..if the patient was NPO would you give him a sandwich if he demanded he was hungry? I work in an innercity hospital and just like fullmoon some people can be quite demanding...my favorite being the homeless drunks looking for 3 hots and a cot during inclement weather..but that's a different thread all together.

You have to remember the patient demanding coffee when they aren't able to have it will be the first to list you on a lawsuit when they go into CHF from being overloaded.

As far as being the worst day of the patients life. The way the OPs patients acted was completely unacceptable and being in the hospital isn't going to turn a usually mild person into a violent person..it just isn't.

It wasn't even about the coffee quite frankly. It was about not being able to get what he wanted. Come on now most reasonable people won't be embarrassing themselves(naked in bed because he threw his gown off? That's pretty atrocious behavior) over a cup of coffee. Nothing was going to make this patient happy..no sense in trying to be rationalal with complete irrationality..you are going to get absolutely no where.

[Accolay]

I'm in an 80s mood...so bear with the references.

Patients like this remind of a line from The Three Amigos: "Could it be that once again you're angry at something else and are looking to take it out on me?"

Easy Armchair Nursing aside, he's fluid restriction, but is he restriction restriction? Is this guy supposed to //always// be on fluid restriction and is he //always// noncompliant?Depending on the situation I think I probably would have tried giving a small cup of coffee, establish the relationship, educate, lay down some ground rules, you know, plan of care and go from there. (I should patent that rhyme) And always listen to Swayze, which by the way should be standard nursing orientation and totally applicable:

Honestly, really honestly, your response to a patient depends on how much junk you've already had to deal with that day. You're only human. Maybe you've already got a really sick person down the hall. Maybe this is the second guy like this you've had today. Maybe even if you're trying everything you can with this guy he's still verbally vomiting all over you. There's only so much one can take. It depends on your hospital and unit policy. Depends if you have backup when you tell the patient "no." But your response (especially when you're already in the weeds) will show what kind of person you really are, and I think you did ok. As far as the early discharge: I have no qualms in letting someone sign out AMA if I tried. If you're already deep in it on your shift, sometimes you just can't do it and have to let these guys out the door. That's unfortunate maybe, but that's the truth. And the truth hurts.

I feel like a lot of comments on this thread could possibly come from a place of having a more normal patient population. However, those with experience where ornery patients may be more frequent, the nurse will have an entirely different orificenal of response. Psychosocial stuff aside doesn't change that this guy, for whatever reason, was being a jerk. Dude needs a Care Plan to address this, which probably wont be completed upon this hospital visit.

The verbal abuse: "It's not me, it's you." Don't feel bad because someone else is a jerk. But in saying that, don't ever anticipate what a patient is going to be like because someone else told you or gave you report that's what they're like. That will always set you up for failure. Always be direct and on the level with patients like this. Never beat around the bush. They can smell a fake from a mile away.

[NunNurseCat]

Do not feel bad.

The man chose to leave. He requested to go. He signed the paperwork. Those were his decisions, and he is responsible for the consequences of his actions.

If he had been as peristent on staying as he had been about the coffee, then he would have stayed.

Perhaps he got home and relatively thrived in a less stressful, do-as-he-likes environment.

I don't have time to read all previous comments, but if someone has said the same thing I have, then that counts for something too OP.

[Jbgood]

The fact is, the doctor put in the discharge order and he signed it so it's no longer your concern that he's manipulating the situation saying he now wants to stay. You did the right thing telling him he had to leave and as someone who was A&O could have taken his butt right back to the ED. I don't work medical, I work psych and we have psychiatrists put in discharge orders all the time for patients who manipulate and try to overstay their welcome. For us, the patients don't even have to sign the orders to leave, we can put on the papers that they declined to sign and send them on their way. Sometimes we will even have security standby in case they get violent or otherwise refuse to walk out the door. Bottom line, doctor ordered discharge, so just document and then wash your hands of the situation.

As far as you not being able to get over the verbal abuse and name calling, I know it's tough. I deal with this behavior all the time in psych and though I don't have the thickest of skins I try to just tell myself this "I'm getting paid to be here and at the end of the day I get to go home to my dog and my kids, happy and healthy while patient X has to deal with whatever mental, physical, or drug issues they have. Boy, am I glad I'm not them!"

[Rhody34]

Interesting discussion. Sorry this happened to you!

[Sour Lemon]

The people saying they would just give to him..if the patient was NPO would you give him a sandwich if he demanded he was hungry?

Yes. I've done that, too. If the patient is of sound mind, understands that he cannot have surgery after eating, and chooses to eat anyway- that's his problem. The doctor is informed, of course ...and the two of them can hash it out until they reach some sort of conclusion.

[Zyprexa]

He was taking up a bed. Be glad he's gone. I would have ripped his Foley out with the balloon still inflated, to be honest. You handled it much better than I would have. Why do we even bother with such disgusting, worthless, evil patients?

Have fun with the urine retention/pulmonary edema, buddy