Coumadin, yes or no?

ANPFNPGNP · Feb 3, 2010

Thanks for all of your input. We thought about the Greenfield filter, but the patient has no insurance, and would have to go into Boston for the procedure so he can get free care. That's unlikely to happen-he has no family and won't go of his own volition. I'll probably do the coumadin and hope for the best. He's unlikely to be compliant, anyway. He'll come in for his INR checks, as he likes to come to the clinic, so we'll be able to keep an eye on him. Poor guy....

I don't feel sorry for him - he's responsible for his actions, including the alcohol abuse!

allnurses Guide · Feb 3, 2010

I don't feel sorry for him - he's responsible for his actions, including the alcohol abuse!

That's certainly your prerogative, and I can see how someone might feel that way. These people are frustrating as hell to work with. I am a firm believer in personal responsibility and accountability, but I still have compassion for him. That doesn't mean I condone or excuse his behavior, but seeing the toll mental illness and alcoholism take makes me sad. Having bipolar disorder is not a choice he made; perhaps the alcohol abuse was, and maybe still is a choice to some degree. We, as a society, do such a horrible job at dealing with mental illness, but that's a rant for another post. Working a few hours a week at a homeless shelter has certainly opened my eyes, and it has also touched my heart.

BTW, this patient came to the health center today and I did not put him on coumadin. I think he's too high risk at this point in time.

ANPFNPGNP · Feb 3, 2010

That's certainly your prerogative, and I can see how someone might feel that way. These people are frustrating as hell to work with. I am a firm believer in personal responsibility and accountability, but I still have compassion for him. .

I worked in mental health for years as a RN and I saw many people who should have been in jail instead of getting "3 hots and a cot" in a psych/detox facility. So many of "those people" had nothing wrong with them mentally, yet they were being coddled by the health care system and given mind altering drugs to control their behavior. They had no problem lining up to get their meds - they looked forward to it! A lot of them would "act out," b/c they wanted to get "wasted" on various drug cocktails. If they faced the consequences of their actions, I can assure you, they would have either become productive members of society, locked up in a prison or died.

Sure, there are people who truly have mental disorders, but I can assure you, they're in the minority. The one diagnosis I used to get a kick out of was "Explosive Personality Disorder." As if that should even be a DSM IV diagnosis!

allnurses Guide · Feb 3, 2010

ANPFNPGNP-

I did not intend for this to ignite a debate on mental illness. You have significant experience in psych, which I do not, which has shaped and influenced your perspective. I feel it's my obligation to give the best care to all my patients, regardless of the baggage they carry. I may not like them or the way they conduct their lives, but if they come to me then they are going to get my best effort. That's why I posted looking for input on how to best help a patient. Nothing more, nothing less.

silas2642 · Feb 4, 2010

I have a patient who was admitted to the hospital today for a DVT (his 2nd) in his thigh. He has all sorts of medical issues, and should be on anticoagulant therapy for the rest of his life. But here's the catch-he is at great risk for injury due to active alcoholism and homelessness, and is frequently falling and getting beat up out on the streets. He's had some pretty serious injuries over the last few years, and I'm afraid that anticoagulating him is going to leave him vulnerable to a serious or life threatening bleed. Of course, the flip side isn't great either-he's at risk for another DVT or PE if he's not on coumadin. He'll be seeing me for followup, and I'm not sure what the best course of action is. Any thoughts or advice?

What does your attending think? Why is he clotting, and has he been referred to hematology? Is he an appropriate candidate for a greenfield filter?

littleredmare · Feb 5, 2010

Any sort of cancer history? A lot of folks who end up with clots have a malignancy floating around somewhere...or are bound for one.

akoster · Feb 6, 2010

What about something like aggrenox. Its not optimal but either is your situation. I have seen high risk patients like yours not placed on coumadin because of many of the same reasons and we just did the best we could and documented the risks both ways.

allnurses Guide · Feb 7, 2010

I am this patient's PCP-I don't work in a hospital setting so I don't have an attending to turn to. Fortunately, I have great colleagues (MD and NP) whom I have discussed this situation with ad nauseum. The patient is homeless and non-compliant with meds, so he's probably not going to take the aggrenox anyway. I tried to get him to at least take regular ASA, and gave him some. He might take it for a few days and then forget all about it. Putting in a Greenfield filter is a great solution, but he won't agree to go to the hospital that will accept uninsured patients. An extensive coag/heme workup was not done for the very same reason-lack of insurance (the hospital he was admitted to for the last DVT discharged him pdq once he was stable-they're not going to eat the cost of a big workup). Again, he could have all this done if he would be willing to go into Boston, but he isn't. So...all I can do is talk to him when he does come in to the health center about the risks, his options, and the danger he's in. Ultimately, it's his decision. I believe he is capable of deciding for himself, and he has chosen (for now, anyway) to not do anything. He knows my feelings about the situation, I know his, but it's his decision not to be compliant with meds and not to pursue other avenues of treatment. I'll keep try ing to persuade him when I see him, but I'm not optimistic for him. It's very sad.