Could I have done something differently?

Esme12, ASN, BSN, RN · Jul 27, 2017

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thread moved for best response

allnurses Guide · Jul 27, 2017

Since patient satisfaction is a big part of what we do and there would be no down side to asking, I personally would have called the doctor back and requested a q4h (or whatever was appropriate timeframe) prn dose. The worst that happens is the patient/family see you advocate for them but the doc says no.

NightNerd, MSN, RN · Jul 27, 2017

Especially if your assessment showed that the patent was in pain, you certainly could have justified doing what the poster above suggested. I also would have personally encouraged then to at least take the dose that is available now, and in 3-4 hours, we have evidence that this med only treats the pain for so long, in which case we can definitely ask for a PRN to be available that covers that window.

So he refused to leave the hospital even though he was being discharged? Whaaaaa? Did he just get to stay? Where I work, if the doc days you're ready to go, you either go or security will escort you out.

allnurses Guide · Jul 27, 2017

I believe Medicare allows people to appeal their discharge if they feel they are being pushed out too soon.

Sour Lemon · Jul 27, 2017

Next time, just ask and let the doctor be the "bad" guy.

MurseJJ · Jul 27, 2017

Think you got great advice here. In situations like that I would say why don't I give this to you now so we can get your pain under control, and I'll talk to the provider to get something ordered as needed so that if you need it I can give it to you to keep you comfortable.

Then if that doesn't work, I'll just ask the provider to come speak with them after explaining the situation.

Been there,done that, ASN, RN · Jul 27, 2017

Patient and "the sister" are frequent flyers. "The sister" has nothing to do with the patient's plan of care.

You will get to know the flyers. Nothing you could have done differently, you asked for a doctor's order.. the frequent flyers did not get what they "thought" they wanted.

What they want is attention. Brush up on borderline personality disorder.

Best of luck, it's a jungle out here.

Kooky Korky, BSN, RN · Jul 27, 2017

Ok, I had a difficult patient this week. It's my first week off orientation and I wanted yalls opinion on if I handled it adequately. The patient was suppose to be discharged, but he and his sister objected and refused to leave. The patient said he wanted nothing through his IV, pain or nausea meds included. The morning shift discontinued all IV meds. He later complained of pain. I called be Doctor, who gave an order for a one time dose of something for pain. The sister was not satisfied with this. Wanted me to call the doctor and get something routine. I told her I already called the doctor and he ordered what he thought adequate. She was mad, called the nursing supervisor, and they eventually got an order for something routine. Did I do everything I could have? Was there something I could have done differently?

You should have asked the doctor for the routine pain med the pt wanted. If doc refused, the pt/sister can go see him at the office or call him on their own.

Iker · Jul 28, 2017

1.) They did appeal to Medicare and they stayed an extra two nights, paying out of pocket. Medicare saw no reason to keep them there. He had a pretty minor problem, nothing critical.

2.) The patient took the medication, but the sister made it quite clear that they would be expecting more pain medicine.

3.) They gave no preference for pain medication. They said he's hurting and needs something for pain. I should have questioned further as to what kind of pain control they were expecting.

4.) As far as the doctors were concerned he was discharged. They saw no reason to keep him, so I think that's why they were being conservative with the oral pain medicine.

5.) The sister of the man made all of these requests. I told her I called the doctor and that's all he ordered. She insisted I give her the night hospitalists number (we are a small hospital, so we only have one night hospitalist) and give the phone to her. I was not comfortable doing that.

brownbook · Jul 28, 2017

I think you handled a really odd situation as best you could at the time. I probably would have done the same and in retro spectroscopic vision have felt I could maybe have handled it better. You are unlikely to come across that type of situation again.

You comment #3 about "question further as to what kind of pain control they were expecting" is right on. In difficult pain control situations I finally learned to start asking the patient and or family what they want, what have they used in the past, what works, what doesn't work, what do they expect, ect. before I talk to the doctor.

JKL33 · Jul 28, 2017

Thanks for posting this interesting situation. It's more than it appears on the surface because of the Medicare appeal issue. I'm in the ED and can't say I've ever dealt with this.

In my career I've enjoyed looking into things like this when I have time. I would imagine Medicare has resources for the legal ways that hospitals must handle this situation. For instance, are treatments continued even though it could be said that the medical staff deems them "unnecessary?" Or do providers have the right to essentially say, "In my clinical opinion, the patient is ready for discharge and therefore I am under no obligation to continue ordering xyz treatment."

I don't have the answers but it's an interesting question. Either way, I would've called the doctor back. I'm just done arguing with patients. If I get the slightest whiff that they're not happy I pose the problem to someone with the professional capacity to alter the plan. I also do as brownbook: find out what it is they want. Not so that we can give them #100 oxys if they want them, but so that we are all on the same page.