i'm a newish rn work in neuro med/surg. i got a 30-something year old patient who has a highly unstable spinal fracture from a fall---bone fragments everywhere...80% spinal canal is compromised around the l3 level....our neurosurgeon started cancelling surgeries to fit in her necessary spinal fusion (7 hrs). he ordered strict flat bedrest, pneumos, logrolls, foley until her brace is made and/or surgery is done.
she will not comply with any of this business. she wanted seven other opinions and until she got her seven opinions she did not want to comply with anything including the basics: foley and/or bedpan, pneumos/teds, and staying in bed. nurses and mds talked to her and she says "it's my right to refuse care" and i have a right to other opinions (after 1 hour of discussion, she finally agreed to 2 other opinions), etc... this morning (5 am) i noticed her cruising around the room in the teds she put on herself sometime overnight with no non-skid stockings (might as well be ice skating in there). she is well aware of paralysis/neuro damage consequences since she's received several hours of counseling from the staff.
i tried the calm, caring approach, and i tried the vivid explanation of consequences approach ("one of these times you get up, you may move wrong and send a bone fragment right through your spinal cord that's why we're encouraging bedrest at this time..."). she'll comply for a bit and then sneak around and do her own thing.
what the heck should we be doing with her? any suggestions? i've never had a patient refuse things like having the siderails up and bedpan use. there's no previously diagnosed psych problems or anything obvious. should i just say "fine do what you want" or keep encouraging compliance like a broken record. any tips? similar problems? we're all stumped.
Apr 15, '04
Document, document, document. CYA. I would document every word of teaching and every non-compliant thing you catch going on. You can't force a patient to be compliant with what's best for them.
Apr 15, '04
We documented everything--I'm not worried about having some legal consequence if something were to happen, just thinking she's just in some denial or desperately wants to be in control.
Apr 15, '04
I second what memphispanda said---document your @$$ off, this patient sounds like the kind who'll sue the pants off you and everyone else when she injures herself beyond help and wants somebody---ANYBODY---to pay for it. :angryfire
Apr 15, '04
[/B]Kelly's psych consult: This gal read her "patient's rights" brochure and is all of a sudden on a power trip..."Look someone gave me the right to say no, and so I'll just exercise my right over all these nurses and doctors who think they know everything...Ha Ha! My opinion is king for once! Whatever I say is goes! This is great!" And I'll just do some stupid stuff and when the nurse tells me "no", I'll get another opportunity to tell her I'M QUEEN and not her![B] Better yet, I'll do a bunch of dumb stuff and when nothing bad happens I'll be able to prove that I WAS right the whole time and this bedrest thing was just a bunch of hogwash.
Apr 15, '04
As frustrating as it is, a patient who is not suicidal/homicidal, or has not been declared incompetent to make decisions for herself/himself has the right to make a bad decision. That means refusing treatments and care. The best thing you can do is to educate your patient about her illness, reasons for care recommendations, and risks of non-adherence. Like the others said, thoroughly document your conversations with the patient. From that point on, it's up to the patient. If you feel that it's warranted, a psych consult would be a great idea. I had a patient once who refused to remain on bedrest, got up to the bathroom, threw a PE and died. Of course the family tried to sue, but documentation of my teaching and her non-adherence saved my behind!
Apr 17, '04
She's refusing all of it? Then why is she there? This is an issue for the surgeon who needs to discharge her pronto. As the patient, she has basic rights but she also has a basic responsibility and if she isn't accepting any care then she is wasting a bed and should be discharged. There is no point in her being there. Get with risk management and tell her that if she isn't accepting the treatment then she should go. The case manager from her insurance company should also be in on this. They're not going to pay for somebody to lay around and get room service on their dime while she possibly delays or endangers her recovery.
Apr 18, '04
I'm all for a little "social intubation" for her own good! A little Nimbex goes a long, long way....
Apr 18, '04
Might also inquire if she realizes that depending on whether the dr has ordered certain things, and she refuses she is refusing reasonable and customary care and the insurance "could" refuse to pay for her stay. They will kick out a hospital stay when someone signs out AMA and not pay for a thing. I imagine they "could" justify not paying for a stay in which the patient refuses resonable and customary care also.
So make sure it is all documented, CYA so when if the insurance doesnt pick up the stay she cant find some glitch to sue on and pay the bill that way.
Apr 18, '04
I think it's really hard to watch people make decisions that we feel are bad. It's also hard not to blame ourselves when the obvious consequences of these bad decisions come to be reality... even though we know and understand that others have the right to autonomy, we still think that maybe we weren't clear enough, or we must have done something wrong...
In my personal experience in living, I've seen that the decisions that people make always reflect what they believe to be right at the time. So in some way or some form, your patient thinks that she is doing the right thing for her. I can't get into her head, but I agree that her behavior might be an expression of control over a life that has gone completely out of control. But I wouldn't assume that. I wouldn't assume anything without finding out from her directly what her reality is.
It may help to change your entire goal from gaining patient compliance to understanding your patient's reality. In a practical sense, this may be difficult because she has already labelled hospital staff as the enemy. But you can still try. Perhaps you can say something like, "I can understand why you're so frustrated, you probably think we're trying to control you and you don't like that." She can either affirm, deny or say nothing. If she does say something, I would lay off trying to convince her as to why she is wrong. Just give her an open ear. Portray to her that you are interested in listening to her and that you have respect for her and her opinion. In this way you may be able to develop trust, and once you have trust, then you can mutually explore other options than her current behavior.
Hope this helps.
May 26, '04
Late update---this gal refused her surgery, stuck around an extra day then was discharged. I did listen to her talk for a long, long time as did every other nurse and her primary doctor. The only thing she said was that she didn't want to be cut open unless three people agreed. The 3rd surgeon said he didn't want to do surgery on her if she would be non-compliant (she didn't want a catheter during or after surgery, didn't want to have to be in bed, didn't want to wear a brace, etc...These were "non-negotiable".) so he recommended "no surgery" and she opted for no surgery.
She walked out carrying her TLSO brace in her hand. C'est la vie
May 26, '04
That's my theory, if you're going to refuse everything, then what's the point of you being here? That's usually what the dr. asks, before writing the discharge order.
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