Case Managing a patient who doesn't want you.

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Specializes in Addictions, Psych, Critical Care, Hospic.

I have recently been assigned to case manage a patient with advanced COPD. Typically nested and unable to leave couch to answer his door. Currently receiving hospice aide services 5 days a week. Lives alone, depending upon a step daughter to meet any and all needs.

The issue is that he is sarcastic, rude, unwilling to explore options that might help his breathing while refusing SW, Chaplain services. He verbalizes to his aide that he does not want skilled nursing, social work services or chaplain help. He only wants the services of a HHA. She provides him with meal preparation only. Step daughter has employed a private aide to come 5 days a week in the am to bathe.

Because the agency is struggling to remain afloat and holding onto those few patients they have, I am in a quandary. The patient is clearly hostile to all SN attempts at interaction.

I am the only option for case managing due to low census.

It is extremely uncomfortable every time I visit due to his sarcastic comments. It feels like, "******* in the wind." I have developed a dislike for him. as a person and dread having to return for another, "visit."

Please help. I am clearly aware of the dynamics occurring as well as the personalizing concerns. Nevertheless, I feel helpless to overcome.

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If you're stuck with him develop a thicker skin, go get a set of vitals if he'll let you, document as deferred that which he won't let you do, write a note with "just the facts, ma'am" about his refusals of care.

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Keep in mind that sometimes sarcasm is sometime a way of hiding pain. A lot of time COPD patients are angry because they are scared. Might try a join visit with the SW. Even though he did not want one. If SW can just get a foot I the door it might help. Listen for the hidden meaning behind the anger. Remember it's only an hour out of your week, it's the end of his life

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Specializes in LTC, Sub-Acute, Hopsice.

SuesquatchRN, Just what I would do.

I have found that sometimes just doing a "just the facts,ma'am" visit for a few times, never overstepping HIS boundries, may lead him to trust you a bit and allow you to finally break through. Write as much of a note as you can, using observation if he won't answer your questions and make it fast. He doesn't want you there right now. And yes, develop a thick skin. You may dread the visit, but psych yourself up and smile so you never let him know you don't want to be there. I've been in this situation, and most of the time have been able to break through at some point, either by killing 'em with kindness or because I walked into a mess and was able to clean it up and make the patient comfortable (which they didn't think would happen, ever) and then I was "da bomb".

Good luck, and keep up updated.

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I'm only an Aide, but I come across this situation sometimes. I like to go in with a question, instead of an answer. "What can I do for YOU" as opposed to "I know what's best for you, you need to listen". Maybe you're already doing that, if so I apologize.

Also, by the time they make it to hospice they've usually gone through the "system". Lots of doctors, nurses, and hospital CNAs. Sometimes not getting the most personalized care, and their trust is long gone. You usually have to work twice as long and hard to win it back. But that's another gift of hospice - giving someone their humanity back!

Just my $.02 from the cheap seats :)

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Specializes in Leadership, Psych, HomeCare, Amb. Care.

Sarcastic, rude, swears...all behaviors often exhibited by people who are scared, angry, in pain. I know I'd be scared and angry if I was dying. Hopefully, I'd be a gracious inspiration to all...but I could have such a difficulty coping I'd come across like a total jerk.

What was his personality before he got sick? Is the dislike of him so much, or anger over having to keep seeing someone who is rejecting your help?

Maybe instead of looking at him as a case to be managed, look at him as in crisis, with you dropping in and seeing what help, if any he may need. A patient is entitled to autonomy, which trumps your agency's financial woes. Unless you can find a way to relate to him on his level, it may be best to pull out graciously, leaving the door open to later return if needed.

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I've got a patient right now just so! Just document the facts, including that he refuses treatments, visits, etc. Be polite, even jolly if you can manage it, and try not to take it personally.

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Some times some people can be annoyed by ' jolly'. Being nice, being respectful

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Sorry. I hit these d button by accident.

Being nice, being respectful, cordial, understanding, honest and sincere may work better.

My concern is that being jolly to this person may come across as diminishing their fears and feelings.

I always try to make sure that I start off with respect and understanding, and if I don't understand their situation, I apologize and tell them that I don't, but that I am hoping to try and get there if they will help me.

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Sorry. I hit the send button by accident.

Being nice, being respectful, cordial, understanding, honest and sincere may work better.

My concern is that being jolly to this person may come across as diminishing their fears and feelings.

I always try to make sure that I start off with respect and understanding, and if I don't understand their situation, I apologize and tell them that I don't, but that I am hoping to try and get there if they will help me.

Sent from my iPhone using allnurses.com

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