Do you ever confront patients about this sort of thing?

[BlueDevil,DNP, DNP, RN]

This is long. Thanks in advance for your patience.

I have a patient that I have trying to support in a myriad of ways for over a year. He is homeless, but used to be working and was taking very good care of himself. He belonged to a gym and was in very good shape, always well groomed due to access to showers. Kept his laundry clean, etc. I often saw him in his work uniform, which he had dry cleaned so it was always pressed. He ate well. He did suffer from depression, but took his medication and did not drink, take illicit drugs or use or request any prescription narcotics.He just seemed down on his luck, and couldn't save for an apartment (child support, which he paid diligently, ate up a lot of his pay).

I was moved by his struggle. I made a lot of calls on his behalf, got him moved up on the list for housing from 2000+ to #110. I used resources I have in the community to get him other assistance. Every time I had something set up for him, there would be a problem and it wouldn't happen. He didn't show up for his housing interview, and said his boss made him work and he didn't have minutes on his phone to call and reschedule. No other phone was available. blah, blah, blah. Lots of excuses. He embarrassed me by failing to keep up his end of commitments he made through organizations I set him up with and did him favors as a professional courtesy to me, skipping other people who were really ahead of him for services because I vouched for him and said he was deserving and would meet his return service commitments. He didn't.

I stopped trying to help him. Of the course of the year I have watched him deteriorate. His depression got worse, and then he started asking for pain meds. One BS story after another. And of course, he turned out to be "allergic" to everything except oxycodone. He got fired for an assault at work. Stopped maintaining his child support, his hygiene, etc, etc.

Still, when he comes to see me, he is quiet, concillatory, begging for help, meds, etc. Recently told me a story I will not elaborate on that I told him point blank I did not believe (and it really is preposterous), at all. His "injuries," more specifically the lack thereof, were inconsistent with the story, and I said I'd give him 1 oxycodone tablet to tide him over until I could get the records from the ED visit he stated he had made the night before, and he had to take it right in front of me (I have suspected the oxy is for sale, not for personal use). He declined, stated he only wanted it for sleep at night. I didn't give him any, he left.

I got the ED records. Only part of the story is true, basically that he went to the ED. That part is true. The rest of the details are drastically different (he greatly exaggerated the version he told me). They worked him up, didn't find anything wrong with him and discharged him with directions to use ibuprofen for pain. While he as there, they did give him dilauded for his c/o severe pain.

I am finally getting to the interesting part. I have the nurses notes. During this stay my pt, who treats me as if I descended from Mt Olympus, did the following:

1. threw a cup of coffee at his nurse apparently because it was cold, while cursing at her.

2. called his nurse a "$@#$%#@!" whore

3. was apparently very calm and cooperative with the physician, and then hearing the MD give the dilauded order waited until he left the area, and said to the nurse: "You heard him b!#$h, go get my effing medicine!"

There were a few other things documented, but to put it in a nutshell, he behaved like a total jerk. I suspect he is a total jerk, and has been lying to me and manipulating me for a year. Needless to say, I will not go out of my way for him again.

The question is, would you ask a patient about these behaviors? I admit, I spent many a shift in my career putting up with that kind of nonsense and I may be personalizing it a bit too much. That, plus my extreme disappointment in this patient, has more more angry than I ought to be. I know, rationally, that there is nothing to be gained by this, and I don't want a confrontation, but I would at least like him to know that I know, that I am on to him, lol, and that I am not fooled any longer.

thoughts?

[traumaRUs, MSN, APRN]

I work with a very large group of noncompliant, often very difficult to deal with pts. My nursing background is inner city level one trauma center ER so this is what I do:

1. My pts are chronic - I see them every week. I believe little of what I can't document myself on exam and/or have charted in the EMR (I have access to all the EMRs from all five hospital systems in the areas).

2. I don't confront my pts about their poor behavior in the ER unless it impacts the care I provide.

3. I don't prescribe narcotics on any type of chronic basis - thats for the Pain Clinic and/or their PCP to control IMHO.

4. I don't go out of my way for pts and don't call in professional favors unless I've know the pt for several years.

I think you have done way above and beyond. I'm sorry that you got burnt. I would not confront him because it just won't matter in the scheme of the care you provide. The ER documented well and it seems like his behavior will certainly affect the care he receives there.

However, if I have a pt who swears at me, attempts to hit me, spit on me, etc., I file and press charges and yes I have them jailed. You know what? In jail, my pts come to dialysis three times/week, stay on for their prescribed amt of time and take their meds....hey maybe I've hit on something....lol

The last thing I do (and I do this all the time) but I document, document, document and I use quotes for what the pt says to me. My ipad Mini gets a work-out but I know I'm accurate.

[Corey Narry, MSN, RN, NP]

This is long. Thanks in advance for your patience.

I have a patient that I have trying to support in a myriad of ways for over a year. He is homeless, but used to be working and was taking very good care of himself. He belonged to a gym and was in very good shape, always well groomed due to access to showers. Kept his laundry clean, etc. I often saw him in his work uniform, which he had dry cleaned so it was always pressed. He ate well. He did suffer from depression, but took his medication and did not drink, take illicit drugs or use or request any prescription narcotics.He just seemed down on his luck, and couldn't save for an apartment (child support, which he paid diligently, ate up a lot of his pay).

I was moved by his struggle. I made a lot of calls on his behalf, got him moved up on the list for housing from 2000+ to #110. I used resources I have in the community to get him other assistance. Every time I had something set up for him, there would be a problem and it wouldn't happen. He didn't show up for his housing interview, and said his boss made him work and he didn't have minutes on his phone to call and reschedule. No other phone was available. blah, blah, blah. Lots of excuses. He embarrassed me by failing to keep up his end of commitments he made through organizations I set him up with and did him favors as a professional courtesy to me, skipping other people who were really ahead of him for services because I vouched for him and said he was deserving and would meet his return service commitments. He didn't.

I stopped trying to help him. Of the course of the year I have watched him deteriorate. His depression got worse, and then he started asking for pain meds. One BS story after another. And of course, he turned out to be "allergic" to everything except oxycodone. He got fired for an assault at work. Stopped maintaining his child support, his hygiene, etc, etc.

Still, when he comes to see me, he is quiet, concillatory, begging for help, meds, etc. Recently told me a story I will not elaborate on that I told him point blank I did not believe (and it really is preposterous), at all. His "injuries," more specifically the lack thereof, were inconsistent with the story, and I said I'd give him 1 oxycodone tablet to tide him over until I could get the records from the ED visit he stated he had made the night before, and he had to take it right in front of me (I have suspected the oxy is for sale, not for personal use). He declined, stated he only wanted it for sleep at night. I didn't give him any, he left.

I got the ED records. Only part of the story is true, basically that he went to the ED. That part is true. The rest of the details are drastically different (he greatly exaggerated the version he told me). They worked him up, didn't find anything wrong with him and discharged him with directions to use ibuprofen for pain. While he as there, they did give him dilauded for his c/o severe pain.

I am finally getting to the interesting part. I have the nurses notes. During this stay my pt, who treats me as if I descended from Mt Olympus, did the following:

1. threw a cup of coffee at his nurse apparently because it was cold, while cursing at her.

2. called his nurse a "$@#$%#@!" whore

3. was apparently very calm and cooperative with the physician, and then hearing the MD give the dilauded order waited until he left the area, and said to the nurse: "You heard him b!#$h, go get my effing medicine!"

There were a few other things documented, but to put it in a nutshell, he behaved like a total jerk. I suspect he is a total jerk, and has been lying to me and manipulating me for a year. Needless to say, I will not go out of my way for him again.

The question is, would you ask a patient about these behaviors? I admit, I spent many a shift in my career putting up with that kind of nonsense and I may be personalizing it a bit too much. That, plus my extreme disappointment in this patient, has more more angry than I ought to be. I know, rationally, that there is nothing to be gained by this, and I don't want a confrontation, but I would at least like him to know that I know, that I am on to him, lol, and that I am not fooled any longer.

thoughts?

As his Primary Care Provider, you have established a relationship with him and I would think he should be aware that you have access to his previous encounters with other health care providers including the outburst he had during an ED visit. It will hopefully give him the impression that he can't play you for a fool. I admire your work and don't think I could ever enjoy the kind of drama primary care offers though we do have our share of it in critical care.

[zenman]

Just present the facts and at some point you decide when to walk away and spend your time on something or someone who has a better chance.

[BCgradnurse, MSN, RN, NP]

Here's another example of no good deed goes unpunished. I encountered this type of situation several times when I was a PCP. It's difficult to see this happen with a patient you've put so much time and resources into. Im sorry you got burned. I agree with what others have said. Dont go out on a limb for patients that you havent known for a significant length of time. I wouldn't confront him about his behavior, because he will say those that reported it are lying. You can refuse to prescribe any controlled substances going forward, and you can base that on ER reports or prescription tracking. These are the patients that suck the life out of us. You're to be commended for trying to be a good advocate for your patient. It's too bad he didn't see it this way.

[BlueDevil,DNP, DNP, RN]

Thank you for your feedback. I was still unsure, leaning toward saying nothing other than I was no longer going to prescribe narcotics for him and he was going to have to transition to psych services for management of his behavioral health disorder, but he no-showed on me today so it was a moot point.

There are refill requests on my desk for him that include clonazepam, and I have no way to reach him. All I can do is send a message through the pharmacy that he doesn't get refills until I see him, but I don't want him unmediated either. It is a difficult spot to be in.

Primary care is so easy a cave man could do it, right?

[traumaRUs, MSN, APRN]

For my pts on benzos, narcotics, or other controlled substances, I check the IL IPDH site religiously to ensure that my pts are only getting meds from one provider.

[AngelfireRN, MSN, RN, APRN]

I know I'm late to the party, but may I offer a different view? My practice does primarily pain management, and while it's not a popular method, we can use that as leverage to modify behaviors. You act a fool or are noncompliant? You don't get your meds. Keep it up and you're dismissed.

In your case, yes, I would bring it up to him (if you have not already). If I hear that one of my patients has harrassed an ER, another physician, or the pharmacy, I absolutely call them on it. It's not acceptable behavior in our clinic, nor will we tolerate someone who is abusive or disruptive elsewhere.

We live on a state line, and we also use the PDMP/CSMD for both states to ensure no one is double dipping.

Hope things get better for you.

[NPAlby]

Im a Psych NP and see this crap daily, hourly. No need for a big confrontation. No need to argue. Just when he starts asking for narcs explain to him why you wont write the script. And then remind him that you are a PCP not a drug dealer when he starts questioning your judgment.