Why don't docs send these pt's HOME!?

[zofran]

I have been frustrated at work lately when dealing with a few pts.

First guy, admited with pancreatitis, so hes NPO and receiving iv pain medication Q2h. A CNA saw him down in the cafeteria eating a cheesburger, and staff from the other side of the hall saw him take a large cookie off a dying pts berevement(sp?) cart that is sitting in the hall for the pt family! Of course I confronted him and he denies it. I document, tell the md, but nothing is done. Same thing the next day, a cna saw him in the cafeteria eating bacon and eggs. I call the md...nothing.

Second guy, has had chrons for a long time. Has been on narcotics at home. He comes in for a bowel resection. All is well until he begins passing gas, gets his diet advanced, and the IV narcs get d/c. Even though the surgon put him back on his reg po narcs from home plus po narcs for breakthrough pain the pt says "its too painful to eat" So the pt begins to refuse food and refuse to ambulate. He ends up on TPN....still refusing food, still refusing to ambulate, refusing to do anything unless he gets more pain meds....This goes on for over a week...ct's and abd series show nothing.....hes just sittng there, taking up a hospital bed, doing nothing but taking po pain meds...FINALLY surgon gets a consult for an hospital doc to deal with this. The hospital doc tells pt he will be d/c to a nursing home if he continues to refuse to eat and walk. Still took the docs 5 more days to get him out.

Third guy, in with sickle cell crisis..due to some lab work, pts hx of leaving AMA, and the fact he has been banned from the hospital down the street, docs don't really believe hes in a true crisis. But they are treating him as it really cant be proven he is lying. So on eve shift he disapears for 3 1/2 hours. Is just no where to be found..They have security looking all over...Doc is notified, documentation is good etc. He comes back and said he "fell asleep" in the lobby. The next day on my shift pt appears to be high on something. Hes so figety, cant sit still, wont stop moving, talking fast, grinding the teeth...not acting the same at all from the previous day. I confront the pt, get the doc up there and again....Nothing is done.

I guess I just don't understand.....If a pt will not comply with treatment or sabotage there own treatment as in these above examples..why cant the docs just d/c them. I would think, if the documentation was excellent, that there would be no reason why not. Do you guys have any thoughts?

[cardiacmadeline, RN]

This also happens on my floor a lot too. Maybe the docs are worried about lawsuits. And don't forget about those patient satisfaction scores that are so important nowadays. The hospital wouldn't want to do anything to sabotage those! After all, health care is now a customer service industry.

[classicdame, MSN, EdD]

reason: lawsuit. They can claim they did not know what they were doing was really harmful (at least not in the same way healthcare providers "know")

Let me guess----------- who is paying for this?

[zofran]

I understand the fear of lawsuits....But if the pt was repeatedlly educated and the documentation was REALLY good...I don't see how these pts would even have a chance of wining a lawsuit.

As for the pt satisfaction scores.....These scores would go up if we could get these noncompliant people out and I could spend the extra time on someone who really wanted to get well. We all know that these pts suck up alot of time.

I just think sometimes these docs need to get a bit tougher on these type of people. Like the npo pancreatitis guy for example. He cont to eat despite the education we gave him. He didn't just do it once. He did it over and over. At the very least the doc could have advanced his diet and switched him prn po pain meds to get him closer to discharge..but no..that guy sat up there for over a week....it just gets frustrating.

[CoffeeRTC, BSN, RN]

I feel your pain from the other side. When they finally get booted from the hospital...they come to my nursing home where they have every single right under the son. Getting them booted from the nursing home is even harder. We have no docs in house to see them, (they might be in once a week) no pain spcialist on staff etc....so you make the appts for them and they cancel or say they are too sick etc but then they can come and go on leave.....

[UM Review RN, ASN, RN]

Where I come from, noncompliant patients usually generate a psych consult. Many times they have some serious issues at the root of it all.

By and large, I've just seen too much to judge, though. Just treat them and hope that someday they'll understand that they need to change a few things if they want to live.

[soulofme]

AHHHHHH...Don't cha just LUV nursing!

[Kylea]

Something you might mention to the higher ups; in the last hospital I worked in, patients were not allowed to purchase food in the cafeteria without the cashier calling up to the floor and verifying if the patient could eat.

[vivacious1healer]

I can totally relate to this topic!

Seriously, if patients are refusing lab work, medications, IV, tests, etc.....after thorough explanation of it all from the docs and RNs, then the next thing to do is discharge the patient. Hell, let them go AMA, I will help them pack and call a cab!

And don't get me started about the 'customer service' crap.....

Don't go to a hospital if you don't want help....there are plenty of people that need that bed and our care!

[nerdtonurse?, BSN, RN]

Nothing works with these people until they decide to change -- no intervention, no teaching, nothing. And since we keep giving them narcotics, then they keep coming back -- why would they not? By giving them the narcs, we are giving them positive reinforcement to keep doing exactly what they are doing.

And with the floor leavers -- call the doc and request an order for a dose of narcan after any "unexplained absence" from the floor. You give them narcan, and tell them they'll get it anytime they leave the floor, and presto, they are ready to go home.

[wooh, BSN, RN]

I just think sometimes these docs need to get a bit tougher on these type of people. Like the npo pancreatitis guy for example. He cont to eat despite the education we gave him.

This guy knows exactly what he's doing. As long as his levels are high, standard treatment is NPO and IV narcs. Eating makes his levels go up. So as long as he sneaks off to eat, he continues to get his IV narcs.

[shiccy]

Unfortunately nobody can control people like this. People are intelligent enough to know that if they asked for nothing when their nurse rounds, and rounds are Q1-2h, then they have the ability to do whatever the heck they want between checks and have no repercussions for it if not caught.

This being said, a patient on my floor had an extensive history of illicit drug abuse. He ended up arresting and eventually dying after OD'ing IN THE BATHROOM IN HIS ROOM. They caught him and sent him to ICU, but the damage had already been done.

Another had "sickle cell crisis" and demanded that IV Benedryl be IVP with a 0.9NS flush "fast because it helps with the itching from the dilaudid better". Since she had a flowing IV, I, of course, refused.

Long story short, people that don't want to change won't. It doesn't matter what you, a doctor, their body, etc are telling them. If they don't want to listen to intelligence and experience, they won't.

As far as people leaving the floor when they're not suppose to, my hospital has the ability to put patients that are flight risks in gowns that are purple instead of our normal very light blue. If staff or security sees these patients off the floor they will physically take these patients back to their rooms by looking at their name bands & looking them up on the computers.