Dialysis as a weight loss plan-she's nuts!

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I have a dilemma that I hope you all can help me with. I have a patient that believes that her EDW is no more than 49.5 kg. "I have always weighed 108 lbs. There is no way that I could have possibly gained any weight." Every treatment her BP bottoms out, she passes out or vomits. We have used the Critline and it shows that her actual EDW is closer to 51kg. She doesn't believe this, and wants us to remove more fluid than she has on, every single treatment day. I have tried to explain to her that her symptoms of hypotension, loss of consciousnes, vomiting, dizzyness, cramping are signs that we are trying to remove fluid that is not there. She doesn't want to listen. I have shown her the critline and explained it to her. I have gone over this repeatedly, explaining to her that every time her pressure bottoms out, she is going into shock. She doesn't care. "I'm fine" is her response. She refuses to allow us to give her any fluid to treat the hypotension. I keep telling her that this is not safe, it is not good for her, and that I won't ignore her body's need for fluid in this situation.

Last week, despite a BP that was frighteningly low, she demanded that we remove her needles immediately after her treatment was over. We explained that they were there in case we had to give her fluid. Nearly 30 min after her treatment was over, her BP was 64/15, so I gave her some fluid. She was absolutely livid that I gave her any fluid. I told her that to fail to give fluid in this situation was close to malpractice and that I was not going to jeopardize my license like that and to please not ask me to. I tried to explain that if I called the Doctor, they would only tell me to give her fluid. She didn't want to listen to me. She was furious, because now she comes off of treatment over 50.5 kg.

Today, after discussing this situation with the FNP, she gave me the order to increase this pt's EDW to 51kg based on the critline data, to not remove the needles until the BP is stable and to administer saline when her BP is less than 90 systolic. When told about these new orders, the pt became incensed. She believes that when she talks to her nephrologist he will reverse these orders, and I am afraid he might. So far all he has done is placate her.

The medical director has basically thrown up his hands and is convinced the pt is a whack job and that there is not a lot we can do, pts have a right to self determination, yada , yada. But where does that right for self determination end, and not allowing a pt to cause harm to themselves begin.

This is all very frustrating, and I am curious how you all would handle this situation.

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I would think that the patients right to self determination allows you to STOP the treatment early but does not permit you to leave her on past the limits of the physicians order.

I mean, you can't keep administering a med or other treatment past the stop date just because the patient wants but you can certainly stop early due to refusal.

I think the next step, if her Nephro changes her orders back to a level that is unsafe then s/he needs to be told to come supervise her treatment. Considering the level of risk she (and the doc if s/he buckles) are putting your facility at it may be time to tell her to find another center.

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Specializes in Nephrology, Cardiology, ER, ICU.

As an APN who manages HD pts, I would do just as your FNP has done: raise her EDW. The only thing I would add is that you need to take and document a manual BP - don't rely on the machines. However, when a pt loses consciousness, this is exacerbating cardiac stress and I would give fluids and if/when pt becomes alert and oriented and wants off, off she comes.

This is not good care and will not hold up in a court of law....make sure your is up to date.

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Thanks for the feedback. The amazing thing about this patient is that if she has a hypotensive crisis in the middle of her treatment, she does not want us to stop the treatment, turn off her UF or give her fluids because that would mean she would come off of treatment heavy. She would never want us to stop her treatment early.

I have never had to deal with someone so vain that they would jeopardize their health to maintain their looks. I personally do not understand this. We are talking about a 1.5 kg gain, that is less than 4 lbs! When she was yelling at me about giving her fluids, I have her approximately 2.5 ounces. It just seems to be such a petty thing that she is putting her life in danger over.

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

Perhaps you might wish to discuss with this patient the idea of signing an out-of-hospital DNR order since she is obviously placing vanity above safety.

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Specializes in Nephrology, Cardiology, ER, ICU.

You must operate safely - the pt's well being must take precedence evern over her own thoughts.

I can't emphasize enough how you and your unit will be held responsible for her care in the event something bad happens.

I would seriously consider a family meeting with the nephrologist and the pt. If pt will not agree to safe care, she needs to be discharged unless you want to face her in a court of law.

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TraumaRUs, you have just spoken to my biggest fear. Everything about this screams bad outcome and I don't want to be caught in the crosshairs. Our SW is on vacation, but I am going to advocate for a meeting of staff, family and doctors about this, when she gets back. We can no longer allow her to jeopardize her life and our licenses in this manner. It scares me to death.

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Specializes in Nephrology, Cardiology, ER, ICU.

As it should!

Good luck with the meeting.

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The patient's well-being and your license are what are most important. Having said that, I would:

1. Ignore the patient's request if, they are contraindicated to the patient's well-being.

2. Follow the dr.'s order for the EDW. (That is an official medical prescription. You have to follow it unless you feel it is grossly incorrect and if so, then you would discuss it with the doctor before initiation of the order)

--besides YOU are the one who enters the info into the machine.

3. If your patient is sooo upset, she can refuse her treatment. Have her sign a form to confirm her refusal of treatment or her decision to end the treatment early (an AMA form--Against Medical Advice).

--We can not force someone to recieve treatments and the patient can not FORCE you to give unsafe care.

4. Have your social worker discuss having a psych eval for a possible eating disorder??? or something. She has obviously poor coping/judgement when it comes to her ideas about weight and so on and may need to discuss it with someone.

I hope this isn't too disjointed and remember.....PROTECT your license and your patient.

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Specializes in Nephrology, Peds, NICU, PICU, adult ICU.

OK this is dangerous and a pt can not force you to remove more fluid. I don't understand why you don't just set the goal for the Rx EDW.

"Kids" said it right above, I think you are failing to see that you could be charged with malpractice for removing more than the Rx allows. This women needs a interdisciplinary meeting with the dietician, SW, Nephrologist, CM, and Medical Director (Everyone).

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Specializes in dialysis (mostly) some L&D, Rehab/LTC.

Ask her what medical school she graduated from & ask to see her diploma

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