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Dealing With Noncompliant Patient, "Cherubs on My Coffin!": Nurse in Action

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Specializes in ED,Tele,Med surg, ADN,outpatient,homecare,LTC,Peds. Has 32 years experience.

How to deal with a noncompliant patient?

Hypertensive, non-compliant patient with multiple ER visits and multiple no shows in the clinic

Dealing With Noncompliant Patient, "Cherubs on My Coffin!": Nurse in Action

My mouth fell open!

I rubbed my eyes and read the message from the patient again that had been sent 20 minutes ago! I had just received an urgent warm handoff by phone from one of the phone bank staff that received this message.

The message from the patient stated that she felt that she was going to die. It went on to describe the kind of funeral she wanted, specifics on the coffin-white cherubs on them, and which cemetery she wanted to be buried next to her closest relative!

I glanced at the clock at 2.30 pm and quickly scanned her chart-Young noncompliant female with multiple commodities, on three antihypertensives with a history of manic depressive psychosis, depression, substance abuse, and domestic violence. Was this a medical issue or a psychiatric issue? Only Philomena, the patient could tell me!

I pulled up a phone note and called the five numbers listed one after the other. I was able to leave a message on one of the numbers but the patient never picked up. I looked at the clock - 2:37 pm. I called 911 and was connected to Emergency Medical Services. I read the note out, gave them a brief history including allergies (none), the patient's address, and my callback number. I then called the patient's emergency contact and Linda her friend, picked up. I asked her if she had a number for Philomena. She gave me a sixth number and told me that she just got off the phone with the patient. My mind racing, I casually asked her how she sounded.

"She seems fine. Laughing and talking!"

"Did she sound depressed?"

"Not at all. We spoke for around 20 minutes!"

"Thanks! Let me try that number!"

I hung up and called the patient who picked up!

"Hi, this is Dr. Annie from the clinic. I work with Dr. Smith, your doctor.  May I speak to Philomena?"

"This is she!"

"Hi! Philomena! We got your message. Are you OK? What's going on and how can I help you?"

"Oh! I have a killer headache and feel like something bad is going to happen!"

"I see! Did you take your meds and eat anything today?"

"Yes!  I can't get my pressure under control!"

"Anything else going on? Are you depressed? Do you feel like you want to hurt yourself or someone else?"

"Not at all!"

"OK! I have already called an ambulance. Please unlock your door, get dressed, and have your purse ready. Take your meds in a bag and make sure you have your insurance card. They should be there in the next 15 minutes."

"OK. Thanks! I will !"

"Philomena, call me if you can't get through to the clinic for any issues. May I give you my number?"

She took my number and I hung up.

I called 911 and asked them to connect me to  EMS dispatch. They did once I gave them the patient's address.

I spoke to EMS and told them that it was a medical issue probably a hypertensive crisis and definitely not psych. They thanked me.

I called the PCP  on his cell (he was working from home doing telephone visits )and informed him. He told me this patient's issues were complicated by her noncompliance and psych issues. I give him her number and he told me he was going to call her in the evening. This was a Friday. The clinic was closed for the weekend.

I called back the patient on Monday. She told me that she was in the ICU and her BP in the ED WAS 240/130. Since she was in a different hospital from our system, I did not have access to her information. I spoke to the ICU nurse who cited HIPAA and would not speak to me! I gave her our contact numbers and she promised to have the doctor call back but no one did. I kept in touch with the pt and finally got to talk to her team when she was sent to step down. She was positive for drugs on the urine toxicology screen. She was being treated for hypertension and now Clostridium difficile colitis. Apparently, she was sent home with a prescription which she never filled. She never picked up her phone for 2 weeks. Our calls and messages went unanswered.

The next time she called me she was back in the ED with worsening renal function. She refused dialysis as she stated that she had some bad examples.  Her mother died after having issues with her shunt and a roommate died too.

I discussed her risk factors, family history, and her ongoing issues with her blood pressure. We discussed hemodialysis, peritoneal dialysis and even being on the transplant list.

"I don't want to live hooked up on a machine, I would rather die!'

"I get it that you are afraid but you may not die as soon as you wish. You could have a long drawn out affair and also end up with a bleed or stroke! It is your choice. You are 38 years old and you have your whole life ahead of you! What do YOU want for yourself!"

"I am very independent. I  want to live my life MY way!"

"Alright! It's your body and I will respect your choices. Call me if I can be of any help!"

"Thank you! Merry Christmas and Happy New Year Dr. Annie! Thank you for being concerned about me! I have your number and will call you if I need you!"

"OK! Philomena! Stay safe!"

I had to back off and watch an impending train wreck.

Last week, I called her. She is back in the ED, this time has a head bleed and HTN. She was waiting for a bed upstairs for four days. Dr. Smith and I called and spoke to the ED attending. They thought she was still using drugs in the ED as every time she came out of the bathroom, her pressures spiked up and she looked spacey. I am not sure, why they didn't do a check on her, but then she can be very convincing and talk her way out of anything apparently! Her partner at home is on drugs. We hope she comes out of this, consider emergency dialysis, and get her blood pressure back to a normal range. Otherwise, it is only a matter of time before I see her in her coffin with white cherubs!

It is a hard pill to swallow! You can't save them all! You can only try your best!


References:

Hypertensive Crisis: When You Should Call 911 for High Blood Pressure

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16 Comment(s)

Davey Do

Specializes in around 25 years psych, 10 years medical. Has 42 years experience.

43 minutes ago, spotangel said:
It is a hard pill to swallow! You can't save them all! You can only try your best!

Yes, it is, spotangel, but you can sleep well knowing that you are a strong link in the chain, doing all that you could.

Good article!

 

speedynurse, ADN, RN, EMT-P

Specializes in ER, Pre-Op, PACU.

Yes this article pretty much sums up the role of a nurse in patient advocacy and education, but also demonstrates free human will and life choices.

This is something I saw many times in the ED and made me see life from a different perspective. All you can do is the best you can but in the end, patients have to make their own choices with their bodies.

I know there was a time that literally every single patient I had was uncompliant with treatment plans for weeks in the ED. I was frustrated and tired and concerned about the lack of concern of these patients for long term health issues. Then one day, I had a newly diagnosed diabetic patient as a “hold” admitted patient who actually brought up many questions because he WANTED to learn to improve his health. He wanted to know all about a diabetic diet, what he could eat or shouldn’t, how to manage his diabetes and work, and how to prevent long term complications. It was a moment that I was so glad to be a nurse because I felt that I could actually perform my role and job for the first time in weeks! When I think about all the frustrations of the ER, I also have to think about moments like those.

 

Emergent, RN

Has 28 years experience.

In my calloused opinion,  our healthcare system throws way too many resources at self destructive people like this patient. Hardworking people get to pay the bills. It's a travesty.

Davey Do

Specializes in around 25 years psych, 10 years medical. Has 42 years experience.

16 minutes ago, Emergent said:

In my calloused opinion,  our healthcare system throws way too many resources at self destructive people like this patient. 

👍

Oh, don't get me started!

CommunityRNBSN, BSN, RN

Specializes in Community health. Has 3 years experience.

This is so very much what we deal with in my FQHC. Here’s what happens to us: 

Pt presents to the hospital for the 13th time this year. Is admitted. Then the hospital case manager calls me, huffy and upset because “This patient lists YOU as her primary care clinic. She’s got diabetes and her A1C is 14!  And she says nobody ever explained anything to her, and she has never been prescribed insulin. She says she’s been trying to get an appointment with you and nobody ever answers the phone.”  Okay, well... believe it or not, that isn’t 100% accurate. 

spotangel, DNP, RN, NP

Specializes in ED,Tele,Med surg, ADN,outpatient,homecare,LTC,Peds. Has 32 years experience.

4 hours ago, Emergent said:

In my calloused opinion,  our healthcare system throws way too many resources at self destructive people like this patient. Hardworking people get to pay the bills. It's a travesty.

I hear you and used to think the same way! Sometimes people grew up with minimal coping skills, no role models, beaten down from the get go with social issues like poverty, violence and a host of social issues. Add a genuine psy history and it is a recipe for disaster. Since she is a drug user she is treated by many with contempt. So she is paranoid  about any advice she receives! This decision  not to take dialysis is the only control she has on her life. So my strategy is patience, being non judgmental and open to her calls. I am also honest with her with my best case worst case scenario! I call her in between when she does not need help to check in. I am slowly building trust. By the way she is back in the ICU with the bleed! This time I am having the Headache along with her!

Davey Do

Specializes in around 25 years psych, 10 years medical. Has 42 years experience.

35 minutes ago, spotangel said:

she is treated by many with contempt

Your actions, spotangel were exemplary, using an objective, non-judgemental approach with your interventions whether she be sinful or a salt of the earth.

You did your job in providing quality care and that's what caregiving is all about- even when the individual is self-destructive.

spotangel, DNP, RN, NP

Specializes in ED,Tele,Med surg, ADN,outpatient,homecare,LTC,Peds. Has 32 years experience.

Stop Davey Do! You’ll make me cry!

Davey Do

Specializes in around 25 years psych, 10 years medical. Has 42 years experience.

53 minutes ago, spotangel said:

Stop Davey Do! You’ll make me cry!

 

608725409_spotangelndd.jpg.22ef278fa61764caac8e54758d2aeb3f.jpg

spotangel, DNP, RN, NP

Specializes in ED,Tele,Med surg, ADN,outpatient,homecare,LTC,Peds. Has 32 years experience.

image.png.50d420b865362d526d744b5c61bbd8da.pngThanks Davey Do from Pikachu!

spotangel, DNP, RN, NP

Specializes in ED,Tele,Med surg, ADN,outpatient,homecare,LTC,Peds. Has 32 years experience.

She’s back in the hospital! At least this time she is in our hospital. I spoke to her today! She tells me, “Thank you for checking on me! I love you Dr Annie”!

I used the line from home. “ love you more!”

One hope she stays and not AMA to get her fix . Her ED BP today was 240 / 130!

She promised to call me Monday!

At least she picks up my calls. A tiny step towards trust methinks!

 

 

JBMmom, MSN

Specializes in Long term care; med-surg; critical care. Has 9 years experience.

Thank you for sharing your experiences. Your patient is lucky to have you, and your persistence, in her corner. Some of my coworkers call me the pollyanna because I try to talk to the detoxing alcoholics or drug OD patients like I'm going to change them. But I go back to a patient that was admitted a few years ago after a DUI. I walked into the room a little annoyed that this person was so irresponsible that they could have killed someone! But, I kept those feelings to myself and approached the patient as non-judgmentally as I could. My internal dialogue quickly changed when I saw a patient who was truly shattered by her actions. She really was not in her right mind when she got behind that wheel and she was devastated at where her disease had brought her. She was also a fellow employee of the hospital and was so embarrassed that people might find out. I took care of her that night and at the end of the shift I drove to the car lot where her car was towed to return her keys and cell phone to her. She had no way to contact her family or her AA sponsor without her phone. I didn't hear anything about it for about a year. I was floated to another floor one night and at the end of my shift I heard "are you JBMmom from the med surg floor?". I said yes and I was completely unprepared for the hug I received. She said she had wanted to find me for months, but she wasn't sure whether she should. She said she hadn't had a single drink since the night she was admitted. She also said the way I treated her made her feel like a person and not a monster. And me driving to get her phone and return it to her meant so much so she could reach out to the people she needed. She said she thought about me almost every day and added me to her regular prayers. It was a moment I carry with me through the tough shifts, knowing that if nothing else, one time I made a difference. 

spotangel, DNP, RN, NP

Specializes in ED,Tele,Med surg, ADN,outpatient,homecare,LTC,Peds. Has 32 years experience.

Thank you! That's beautiful! God bless you for showing compassion to that coworker. You turned one life around!

Daisy4RN

Specializes in Travel, Home Health, Med-Surg. Has 20 years experience.

Thanks for sharing your story, reminds us that we should always try even when it seems people don't want help. 

Once I was tasked to be a 1:1 sitter to a known gang member. I think because other people were either afraid or because I was known to be able to draw the line, or maybe devine intervention, IDK. I had done this before r/t short staffing and it was usually a nice break from RN duties. I ended up talking to him about many things that day, I really don't remember all of it but he shared he was brought up Catholic so he opened the door for discussion. We talked alot and I hope I was able to help him on his journey. At the end of the shift he gave me a little plant that someone had brought him. He told me he appreciated the talk, and the fact I talked to him with respect and genuine caring and not like most people had been treating him. It was just a little plant but I was really touched but even more important I hope he was able to move past his mistakes and the guilt he was carrying around and know Gods love and peace.

spotangel, DNP, RN, NP

Specializes in ED,Tele,Med surg, ADN,outpatient,homecare,LTC,Peds. Has 32 years experience.

That's a great share Daisy4RN! Under the gruff exterior many of them are nice people and dare I say Teddy bears! Reminds me of a patient of mine, Peter, from the ED.

"Where the F ----is Nurse Annie! "was the way Peter, a dreaded gang leader would walk into the ED. He had bad CHF and only trusted me! I had apparently calmed him down and helped him, the first time I saw him when he was  in resp distress but still swearing a blue streak and not let anyone touch him to put  line. I was firm but gentle with him and he calmed down. I got his line on the first try, gave him lasix, neb treatment, steroids  and he felt great! Since then he only wanted me to be his nurse even though I was the evening supervisor for the ED and worked M-F. On Saturday if he showed up, all hell would break loose as I was not there to "calm "him! My staff would call me and say ,"Your boy is here!" He ended up on the transplant list and even presented me a gift- my name in Graffiti style! I had it on my desk! Heard he calmed down some as he got older. I lost touch with him. What a character! I loved interacting with him and my staff thought I was crazy! I told him, that he was a fighter and that would keep him alive, if God willed!

spotangel, DNP, RN, NP

Specializes in ED,Tele,Med surg, ADN,outpatient,homecare,LTC,Peds. Has 32 years experience.

Latest update on Philomena!

She AMA from her hospital  room on Saturday as she was so "Hungry" while waiting on MRI/MRA, Venous mapping once admitted----!

She ended up going to another hospital yesterday for SOB and is currently admitted. I spoke to her RN and PA. The plan is to get her BP controlled and then send her home! I requested for a psych and de addiction consult. Again they can only do it if the pt agrees and she is fully with it! I feel like a hamster on a wheel!image.png.3127dfa58f57cef158b4d843171768be.png