Angry patient

[bay bay]

Hi,

I have only been a Hospice Nurse for a few months. I absolutely love it, and feel this is where I belong. My question? I'm having a hard time knowing what to say to a man in his early 60's who is experiencing a huge amount of anger and frustration, which is understandably so. I usually feel pretty comfortable, asking patients about their feelings, and allowing them to express themselves. This gentleman, however, has started to refuse all meds exept for his morphine, and is extremely restless(not due to respiratory distress). When I brought up Ativan, he threw his hands up, and his wife looked at me, like I shouldn't push the issue, so I respected that, and told him so as well. I'm wondering how others handle angry patients, and what might help bring him more at peace with his situation. He has periods of confusion but alert enough to have input in his care. I know this must be a common challange for hospice nurses, but I haven't had to deal with this level of anger yet. I already have a social worker involved. Any suggestions would greatly be appreciated.

BTW, This website ROCKS! I have learned so much in reading threads this past week.

[leslie :-D]

those are the hardest cases, aren't they? there's really not much more you can do; acceptance, understanding, empathizing, having the ativan readily available, encourage him to make the most of his time w/his wife....the largest goal is for the pt. to finish up any undone business, stay ahead of his pain, counsel his wife, and just understand everything they're experiencing. it's perfectly natural to feel like you've been robbed of any remaining time; in awhile he'll be in much poorer condition, and probably won't have time to dwell on what has been dealt. just continue to be there for them, understanding all negative feelings expressed. would he feel better talking to a priest/rabbi? much luck to you and your pts.

leslie

[SuesquatchRN, BSN, RN]

Well, anger is one of the five stages of accepting death, or grieving. I haven't had to deal with this yet, but I think that just acknowledging his feelings would be the most helpful to him. "Yes, it must make you really mad." If you can be more colloquial, "Yeah, it'd piss me off, too." He needs to vent and you need to let him.

And good luck. Hospice nursing must be such a combination of reqarding and heartbreaking.

[tep]

When working in palliative I found humor worked best for me. We all know why everyone is there right?! He definitely needs to work through it but maybe by watching his interactions you could see what type of humor he has and go from there.I know it may sound flippant but it always worked for me, especially with the super cranky ones! Good luck.

[aimeee, BSN, RN]

What about your bereavement counselor or spiritual counselor? Have they visited with him yet? His refusal to take medications might indicate he is angry with himself and punishing himself. Or he might be angry that he feels he is a burden to his family now instead of being able to provide for them and so he is trying to speed things up by not taking his medication. Acknowledge his feelings, keep giving him opportunities to let you know what is behind it.

[mary4192]

Often I have found people are reluctant to accept anything that might be considered a tranqualizer.

Is your patient taking any dexamethasone?? It might be introduced as an appetite stimulant, if that is a problem for him. And he might feel a lot better with some dex and then you might approach him about having something in the house like lorazipam drops to use for restless nights when he can't sleep. After he agrees to let you order them for him and maybe even uses them once or twice you can add that they also can be used for anxiety if needed in smaller doses than for a sleep aid. You might also just want to pass that along to his wife initially.

Well hope it helps, hospice is a very special kind of nursing. I don't think most nurses realize what an honor it is for people to let us into their homes at this time in their lives.

Well that's my .

Mary

[abnerRN]

welcome to Hospice nursing, I too feel that this is where I belong and truly am blessed to be involved in end of life care. You don't mention his disease, but it sounds like he's reaching an end poiunt: By refusing all except pain meds he may be saying he's tired of the fight. Restlessness is quite common near the end, especially if there is unfinished business or the patient is still in anger or denial. Have you offered the services of your hospice's chaplain? Sometimes the patient just needs to be allowed to vent his anger and you just support him. Sometimes they can be drawn out to verbalize what they are feeling, sometimes not. Just be there for him and support him as best you can.

[UM Review RN, ASN, RN]

I've found that most men mask depression with anger.

Women cry; men holler.

That's just the way they are.

[steelcityrn, RN]

I usually like to work my way into his trust. Hear the person out well about his anger, could be about anything besides the cancer. Once its all out on the table, I try to place it then into categories of importance(in my mind for a plan of action) and have the patient focus on whats good about his life, what is he thankful for. Once they pull out of the anger/depression its just a amazing transition and the entire family benefits form it, but most important the patient. As for as the ativan, which should be in the home, you may want to emphasize how it can relax him to allow for easier breathing and cardiac statis. Good luck, one thing in nursing is you never stop learning, and these patients can teach us alot.

[bay bay]

You guys are incredible! Thank you so much! We hospice nurses are definately on the same wavelength. Looking forward to signing on this website again.

[req_read]

bay bay

Patients who are the most "together" and need the least help tend to benefit the most and demonstrate the most gratitude.

Conversely, patients whose learned coping mechanisms are the least effective (frankly dysfunctional) benefit the least and are apt to be the most angry and blaming.

Angie O'Plasty RN made a good point re: men's inclination to express depression as anger. I would add that men are also inclined to express fear and sadness as anger as well.... for as we all know, "Big boys don't cry." It is not okay for us guys to cry, so we cuss & yell.

It is okay for women to cry but not to cuss and yell, so females (at least in our society) are inclined to swallow anger and express it in tears. There are exceptions to every rule of course, but these are trends typical of our aculturation.

So men tend to arrive at their dying process with large reservoirs of unresolved fear & sadness, while women arrive at that same point with loads of unresolved anger.

Resolving or off-loading a lifetime of unresolved fear & sadness by expressing it as anger simply will not work. It may have seemed to work for him during his life, at least to some degree, but dying process reveals the difference between functional & dysfunctional coping mechanisms... in other words, it teaches us how to live.

All of which is very interesting, but when it comes down to your specific patient, the chances of your being able to teach him functional coping mechanisms at this late stage are probably pretty poor.

It sounds like you are already doing as much as anyone could reasonably expect. Just know that you are not the first one to be faced with this extremely uncomfortable type of situation.

[leslie :-D]

req read and angie,

yes i agree that men tend to express their grief as anger and women express their grief as grief (but no anger); and who can blame anyone for being grief-stricken or angry? but i've been very fortunate in that my male pts have openly wept in front of me and i wouldn't be satisfied until they were able to express their sadness; they got dealt a very raw deal which sucks big time and any man should not hesitate in expressing their grief. believe me, if there were facades up before, they didn't stay up for long. i've never had a pt. that didn't cry for their loss of life.....it's always one of my top 3 goals, no matter who the pt is. granted, some pts are more challenging than others in terms of the grieving process, but they all end up afraid & vulnerable. it makes my job easier when one can face their feelings.

leslie