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.

Feel free to take a break.

Use your assessment skills to look at the big picture. This is not about serving a patient a cup of coffee. This is about managing a patient that is declining doctor's orders.

Certainly, an alert and oriented patient does not have the right to abuse a nurse. The POINT is the nurse escalated the event.

"I'm glad he left." Why is that? So the nurse no longer has to deal with a mis-managed patient.. that is clearly unable to be discharged.. and asked to stay? You won't be so "glad" if he comes back in fulminating pulmonary edema and it was YOUR name on the discharge.

The doctor ordered the discharge. The doctor handed the guy coffee.

The nurse did not escalate the event. If she had thrown stuff at him and screamed at him like Gunnery Sergeant Hartman, that would have been her escalating the event.

Kooky...

Come on, you don't really mean that, do you? She'd already discharged the guy, after telling him that he may NOT treat staff that way.

I'll take that for support, in a heartbeat. I would've brought him the coffee myself at that point, seriously.

I agree with you about the support, and I assume Kooky is also kidding about unnecessary pages.

But I think talking with the doctor about what orders she wants followed is a good one.

This thread opened with several PPs stating they would just have brought coffee, and others stating that nurses can get into trouble for actively going against an order (different from documenting a patient getting his/her own drink). Several staff members ended up in a power struggle with the patient and were verbally and, in OP's case, physically assaulted as a result of trying to carry out the doctor's order. When she gives him a cup of coffee, it undermines the efforts of the other staff members.

If she's okay with staff carrying out patient requests that contradict her orders, that needs to be known, and there should be some kind of protocol in place for nurses to cover themselves in those situations.

Specializes in Med/Surge, Psych, LTC, Home Health.
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.

"but could that have made him stay longer in the day, and then I would have had to deal with him even longer?"

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.

Talk to your risk manager, make sure your malpractice insurance is in effect.

For real???? Wow. Harsh.

To be fair, I'm like that before my coffee too.

Specializes in Med/Surge, Psych, LTC, Home Health.
To be fair, I'm like that before my coffee too.

You win. :laugh:

Specializes in Psych, Corrections, Med-Surg, Ambulatory.

I don't think it would have mattered if he'd been given a cup of coffee or not been given a cup of coffee. Five minutes later it would have been something else. The guy is on a collision course with destiny and at this point I don't think it's a matter of education.

The doctor gave him his coffee after she told him he was discharged; I agree it was her way of telling him she was washing her hands of him. Changing his mind about discharge after getting his coffee was just being manipulative and all the abhorrent behaviours would have just continued. I don't blame the OP for not allowing that and sending him out the door.

Having worked psych for the first half of my career, there is one thing I always tell students and orientees: "You can't save someone from himself and it does no good to work harder for someone than he is willing to work on his own behalf".

This is the kind of patient that always leaves you second-guessing yourself because they like to create lose-lose situations. It's unfortunate but you have to just shake it off. Hugs.

All the people saying "just give them the coffee" makes me think of a video we watched at orientation for my hospital. It's called "Give 'me the pickle". I'm not saying to just give in to the patient EVERY time, but weigh the pros and cons. If he's coming close to that cut off line say "this is your last cup until such and such time. You're close to your restriction line." Or "if I give you this cup now, you won't be able to get a drink later." I once had a patient who decided to start doing half cups of coffee to try to save some mls for later.

A paper in the room tracking intake really should have been in the room. The nurses check on these at my facility throughout the shift as it makes it easier for the techs to grant immediate requests for fluid.

Specializes in Clinical Research, Outpt Women's Health.

He made his own decisions and you are not responsible if he chose to make poor ones.

I think I would have given him the coffee, but if he talked to you again that way after that I would have happily showed him the door. Just because a person is sick does not give them the right to treat their caregivers that way.

Specializes in Cardiology, School Nursing, General.

I agree with a lot of these. Not a nurse, but CMA and I had my share of verbally abusive patients. I just gave them what they wanted and went to my OM to tell them what happened, just in case they came back and complained. I always did everything by the book and if they weren't happy, I could ask if they wanted another CMA instead of me.

All the people saying "just give them the coffee" makes me think of a video we watched at orientation for my hospital. It's called "Give 'me the pickle". I'm not saying to just give in to the patient EVERY time, but weigh the pros and cons. If he's coming close to that cut off line say "this is your last cup until such and such time. You're close to your restriction line." Or "if I give you this cup now, you won't be able to get a drink later." I once had a patient who decided to start doing half cups of coffee to try to save some mls for later.

What is your plan when "later" becomes now? Yes, it's slightly possible that some negotiations or concessions may have improved the OP situation. Very slightly, as in - probably not, but I'm not willing to say 100% impossible, and I would at least try. Lets acknowledge though, that patients who would negotiate with you like reasonable human beings are not usually the ones calling you a stupid, lazy, effin' fatass.

Here's the second problem - which has always been the problem with customer service as it relates to patient satisfaction as it relates to things that make patients happy: We're not talking about restaurants or free pickles. We're talking about something that is medically contraindicated (and I'm not going to argue about how necessary fluid restrictions are; the fact is that currently they are generally an accepted part of a plan of care/standard of care for such a patient, which is why the physician ordered it in the first place).

I have no problem with patients refusing aspects of their care or asking for concessions, such as cups of coffee, that may be medically contraindicated. But I think that they should take full responsibility for that, as opposed to making medical providers "give them a pickle." When patients receive care that is out of line with accepted standards, the care team generally retains legal responsibility for that. Conceding while retaining the legal responsibility goes well beyond "customer service." It's pretty disingenuous to conflate the two. This is a hospital. I don't care what the non-medical patient services people say, customer service is not things that are medically contraindicated. Don't you know -- Medical errors are ((supposedly)) the third leading cause of death in this country...?

So which is it? We're killing practically everyone, or we should give people pickles that are medically contraindicated?

Edit from beyond the grave?

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