Need help W/Difficult, complicated Pt.

  1. i need some opinions on what to do with one of my home care pt's.
    i'll give you a little hx. first.

    female, mid 50's, lives alone,no willing family to assist. has chronic diagnoses but nothing that should seriously be disabling according to the multitude of md's who have treated over the years.
    also has chronic pain issues,currently taking meds for same. mild depression/anxiety, controlled w/meds.
    divorced, one child who lives out of state and doesn't really want to be bothered.

    pt. has been on long term home care for about a year since coming out of ltc facility. when first admitted on our program, she was ambulating with walker and doing stairs. in the past year, she has slowly refused to get out of wheelchair (which she had to be used for longer distances) and is now completely w/c bound.

    i'm at my wit's end. i and the md have talked and talked about all the problems she will face and some she has already had due to not ambulating,. she even sleeps in the chair. she has already had cellulitis and wounds on lower ext. due to edema, she won't elevate legs. this is a youngish woman who is sentencing herself to a life of never being able to walk again. we have pt in there again to try and help but i don't see the point. they can't stay on the case forever and she basically won't do the exercises on her own anyway.

    btw, she has a foley , and wears a diaper for bm's because she refuses to get on a commode too.

    should i just give up??? my supvr. of course is aware and obviously i can't make the pt. get up. i just feel really helpless and i guess a little angry. i have a paraplegic that would love the opportunity to have the ability to walk.. i have dealt with plenty of non compliance in my experience but this situation is so frustrating.
    i would appreciate any suggestions or comments....
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  2. 14 Comments

  3. by   GingerSue
    any idea what her reasons are for not doing the exercises or why she is refusing to get out of the wheelchair? (is she having pain, is she weak, etc?)

    Has she been included in the plan of care - has she been asked what her wishes are, what her goals are, what her priorities are? Does she understand what the long-term consequences are? What is her level of intelligence?

    Certainly don't want the cellulitis, leg wounds, edema.
    Is the foley permanent?
    Hope things work out.
    Maybe the PT has some ideas about how to communicate with the lady.
  4. by   nurse4theplanet
    Who is treating her for her anxiety & depression? How agressively is it being managed? I am asking because I get the gut feeling that her non-compliance is stemming from some strong psychological issues.

    She is lives alone with little family involvement. She's wheelchair bound. I assume she is probably not involved in anything outside the home (senior centers, church, etc.) She may not have any interaction with other people besides the healthcare team that makes their visits. It sounds to me like she has just lost the will to improve her life and even live. Until that changes, she will have no motivation to actively participate in her treatment plan.
  5. by   caliotter3
    Agree with everything GingerSue has said. Very important to try to include pt in the process and make certain that it is clear to her that you are not trying to run her life and dictate to her. Have had my share of same type. My last pt, argument everytime, I kept having to remind him that his right to refuse would never be broached and that I brought up subjects b/c of the requirement for me to show teaching/education on our documentation. I also told him that by giving him info, to include any newly avail info, and seeking out his ideas to improve his own care, that I was offering him the possibility to make changes that [B]he wanted. He had such a defensive attitude built up over the yrs that it was difficult for him to see that anyone was even willing to listen to his ideas about things.

    Also, can't help but wonder if there might not be something medically (including worsening depression) that might be behind this behavior. Definitely looks like a case conference might be in order. Good luck.
  6. by   S.T.A.C.E.Y
    You can lead a horse to water, but you can't make it drink.

    If you have honestly put in every effort to help this lady understand what's best for her health, and her depression/pain is adequately controlled, and the supports are there to help her, and she just honestly doesn't want to do it anymore, what more can you do? Personally, I feel that at some point there has to be some expecation on the sick person to want to get better again. It is a sad situation, especially when you see someone else who so desperately wants the opportunity to walk again. Good luck to you, and the doc, and the PT. Hopefully the lady does come around, or the underlying problem is discovered/resolved.
  7. by   KellieNurse06
    well, not to step on any toes here...but obviously her depressionand/or pain is NOT being controlled....just because it "appears" to be from the standpoint of the medical side......obviously it is not or she wouldn't still be this depressed.......think about it...if you were all alone with no family/friends that showed any care/concern...you'd be pretty depressed as well........maybe so depressed that her will to go on is definetly impeded....the old " well if noone cares, then why should I" train of thought. Also has anyone made sure it may be some meds she's on or maybe she needs a different type of antidepressant....you know some people have a hard time being treated for depression with alot of the typical meds that work well for others.......Maybe she feels that if she "helps" her condition worsen that someone will step up to the plate from her family & take care of here....because it would be attention she obviously desperatly seeks...she sounds like a very very lonely depressed person.....just mpo.......I hope I am wrong but this woman screams severe depression & loneliness from what you describe......again ...just mpo... It will be very interesting to know how she does....can anyone get in contact with her family members & try to talk to them??????? Tha's pretty sad that no one can be bothered...
  8. by   rehab nurse
    Hi there.

    I wonder too if there's anything about the pain/depression not being managed aggressively enough that's causing her not to be involved as much.

    I agree with the other posters who state the depression is probably not being treated aggressively enough.

    What is her chronic pain issue? Back problems? What type of meds is she on for that? Chronic pain over a period of time WILL cause depression on it's own. Who is managing her depression? A primary provider or a psychiatrist? My own chronic pain doc sends me to his on staff psych for treatment. I'm wondering if those two issues are bringing her down.

    It sounds like something happened just recently where she started not walking anymore? Does she have sciatica? Just wondering since that is often a main CP issue.

    Like the others said, really not a lot you can do to get her to do anything. It sounds like she's terribly depressed, maybe due to increasing pain. I don't see any further posts about her problems so far, I wonder what her meds are for pain and if they are helping her.

    I can't believe she doesn't move or get out of the w/c to sleep!!! How can she stand staying in one position 24/7?? That drives me crazy, being in one position for more than 15 minutes. It makes my pain so much worse. I'm forever changing position. Sitting is the worst, too.

    Looking forward to hearing some more from OP.
  9. by   Cattitude
    Quote from kellienurse06
    well, not to step on any toes here...but obviously her depressionand/or pain is not being controlled....just because it "appears" to be from the standpoint of the medical side......obviously it is not or she wouldn't still be this depressed.......think about it...if you were all alone with no family/friends that showed any care/concern...you'd be pretty depressed as well........maybe so depressed that her will to go on is definetly impeded....the old " well if noone cares, then why should i" train of thought. also has anyone made sure it may be some meds she's on or maybe she needs a different type of antidepressant....you know some people have a hard time being treated for depression with alot of the typical meds that work well for others.......maybe she feels that if she "helps" her condition worsen that someone will step up to the plate from her family & take care of here....because it would be attention she obviously desperatly seeks...she sounds like a very very lonely depressed person.....just mpo.......i hope i am wrong but this woman screams severe depression & loneliness from what you describe......again ...just mpo... it will be very interesting to know how she does....can anyone get in contact with her family members & try to talk to them??????? tha's pretty sad that no one can be bothered...
    well, there are many issues with family dynamics. it's not always the case of the poor patient with a neglectful family. let me expound by saying this: this pt has a weird personality. she is self centered but not selfish. she is not nasty at all but very expectant of others to do things for her, things that she can do for herself. she has a lot of trouble keeping home aides for any length of time..
    i think she has driven her family away, a little at a time and they can only take her in small doses. she is very needy. i have had to set a lot of limits with her as in the beginning she would try and keep me there for 2 hrs. but, i do like her and she likes me, we get along fine.

    as far as pain control, she is medicated adequately. she has osteoporosis and arthritis and is on fentanyl 100 mcg and oxycodone 20 mg q 4h prn. i have never seen any other pt. ever on those meds unless they had a dx. to support. we went up on meds before and she was so sedated she was nodding off in the middle of speaking. she is treated by pain specialists has had every scan in the book, no one can figure out what is wrong. she is also on meds for neuropathic pain.

    she is also treated by psychiatrist. she reports no feelings of depression, states a little anxious only when aide leaves for the day.
    believe me, i have done a lot for this woman. so much that i had to take a step back because it was draining. that's why i asked for help. i realized that putting pt in is not the only solution, she states it "hurts too much" to get up. i and the therapist tried explaining that yes its going to hurt for a few minutes when you initially move but that the more you do it, it should improve. we also reassured her that if the pain worsens over the next few weeks, we will stop therapy. or stop at any time if she really wants.

    she has expressed a desire to attend a day program to be around and interact with others but at this point, i wonder how realistic this is. i warned her that if she continues in the wheelchair, with current health issues, she may at some point end up back in ltc. she wants 24hr home aide and you don't get that in home care unless you're literally dying.
    so there it is... we've been through all teaching, instruction multiple times. she says she wants to walk but doesn't want to do the work, always has an excuse for why she couldn't do her exercises that day.
    i have tried over and over to find out any underlying reasons why she behaves the way she does.

    thanks!
  10. by   nurse4theplanet
    Sounds like she has some other psychological issues...maybe borderline personality disorder with some co-dependency issues. She needs interaction, probably craves it, but her personalitiy and antics are making it difficult for others to tolerate her. She needs to get out and have a regular routine where she has interaction with others, but I can see how difficult this is becoming for you. Suggest that she find a home companion, a day sitter...sometimes there are other elderly/retired people who volunteer their time. Alot of church organizations have volunteer programs like that.
    Are there any senior centers in the area that provide transportation and activities for people like your client? Have you spoken to her about what she was like before her chronic pain and health issues arose? Was she involved in anything? Did something happen (besides her health) that changed her routines (death of a spouse, loss of work/retirement, loss of a friend, etc.)
  11. by   Cattitude
    Quote from rehab nurse
    hi there.

    i wonder too if there's anything about the pain/depression not being managed aggressively enough that's causing her not to be involved as much.

    i agree with the other posters who state the depression is probably not being treated aggressively enough.

    what is her chronic pain issue? back problems? what type of meds is she on for that? chronic pain over a period of time will cause depression on it's own. who is managing her depression? a primary provider or a psychiatrist? my own chronic pain doc sends me to his on staff psych for treatment. i'm wondering if those two issues are bringing her down.

    it sounds like something happened just recently where she started not walking anymore? does she have sciatica? just wondering since that is often a main cp issue.

    like the others said, really not a lot you can do to get her to do anything. it sounds like she's terribly depressed, maybe due to increasing pain. i don't see any further posts about her problems so far, i wonder what her meds are for pain and if they are helping her.

    i can't believe she doesn't move or get out of the w/c to sleep!!! how can she stand staying in one position 24/7?? that drives me crazy, being in one position for more than 15 minutes. it makes my pain so much worse. i'm forever changing position. sitting is the worst, too.

    looking forward to hearing some more from op.
    i agree about the changing positions. i have frequently told her about this, about muscle atrophy, bone density loss, etc. she always gives me a blank look. she's intelligent and understands but stubborn and willful.
    i have herniated discs and sciatica. i need to change positions and can't stand or sit too long.. i don't know how she does it.
  12. by   CritterLover
    well, if she gets better, she loses you/her aides.

    do you think this could be a reason (either conscious or subconscious) that might be holding her back?

    could there be a part of her that wants to go back to ltc for the social interaction? she sounds very lonely.
  13. by   Cattitude
    Quote from critterlover
    well, if she gets better, she loses you/her aides.

    do you think this could be a reason (either conscious or subconscious) that might be holding her back?

    could there be a part of her that wants to go back to ltc for the social interaction? she sounds very lonely.
    we are long term home care, pt's can stay on our program forever so she at least knows that she'll always have help as long as there are taxpayers:wink2: .
    she definitely does not want to go back to ltc as she has stated that many times. she hates the hospital too. she really like being at home (meaning in the community). she is lonely. unfortunately she can't get out as she lives in a rented apt. in her aunt's house . there are about 3 flights of steps and she must be carried in the wheelchair up the steps by the ambulette driver. they will only provide that service for medical appts.
    so it would be great to get her to a senior center but no way to get her down all those stairs! she can't even get out for a little sunshine in the summer. that's why i want her to be able to walk.

    oh yes, several weeks ago, afetr the aide left, she had a massive episode of diarrhea. she couldn't stand/walk to the bathroom or get herself cleaned up and no one home anywhere to help (it was in the evening)
    she called 911! she requested a female officer, they actually sent one. she told me later that the officers looked at her like she was crazy when she told them why she called. but the female officer was nice enough to help! poor cop, i betcha they didn't tell her about that in the academy.

    thanks again for the responses. i think it may be some borderline personality as someone said...
  14. by   Batman24
    She does sound like a very sad woman. I also wonder if there isn't a bit of a control issue here. She doesn't seem like she can control much else around her so maybe whether she walks or doesn't is one thing she can control. She also gets a lot of negative attention which may be better than no attention at all.

    Could you wheel and deal her a bit?! Look into a great center that has an activity that she loves and make it a goal for her to get there within the next month, etc. Maybe a fun goal would get her going again. And a little tough love never hurt anyone either. Good luck.

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