Dr. gives deadline to smoking pts

numerouno · Mar 1, 2002

You know i'm sorry i am an ex-smoker and thank my stars everyday i don't miss them. Come on now okay people will try and stop several times i myself tried for 6 times. Will this DR. set a limit on that too. I will only treat you if you stop after 4 tries...What happened to the oath he took.(i assume it's a he?) What if we as nurses said you know what i'm not going to take care of noncompliant diabetics come on get real. I have also seen a large number of obese who will not stop eating and are also on vents due to respiratory complications if they lost weight would he treat them then? I also see people who eat poor diets and die of colon cancer or on vents after it spreads to the lungs. This is a cop out on his part recognize it for what it is. It is not illegal to smoke it is to do drugs but we treat them. We all make choices some good some bad and we deserve the treatment of caring individuals. Quite frankly i think it's biased and someone is going to see that. Until he states he is not going to treat all patients who do not try to stop thier poor behvaviors it's plain bias!

Jenny P · Mar 1, 2002

While doing research for a recent panel discussion on patient abandonment, I found alaw site on the net that discussed this subject and copied it because it was interesting.

Basically, it stated that a health care provider may quit providing services to a patient for many reasons including: THE PATIENT REFUSING TO COOPERATE WITH THE PROVIDER AND HIS STAFF. But the provider is not allowed to "abandon" a patient. "Abandonment" was described as a unilateral severance of the professional relationship (by the health care provider) without reasonable notice at a time when there is still a need for continuing health care.

There were a number of other reasons why a HCP could withdraw his services; but I think that in this case, if the patient is unwilling to try to quit smoking, the MD is within the law. Personally, I don't tolerate many respiratory irritants (asthma is so much fun--NOT), and the idea that I could go to a doctor's office and not sit next to a smoker might appeal to me!

This doc may have some personal prejudices (who knows- it's possible that a loved one died from smoking!) that make him too frustrated to deal with smokers. I'd rather the guy spells out his rules and refuse to care for pts. than emotionally give up trying to care for a patient who's non-compliant. After all, OB-GYNs don't HAVE to provide abortions, do they if they are morally against them?

fergus51 · Mar 1, 2002

I don't like it. I cringe everytime I hear the word non-compliant. I don't like doctors imposing their moral beliefs on patients (whether it's abortions or smoking). A doctor is supposed to be your guide, not your boss. They're supposed to tell you what they think, but in the end the decision is yours. I wonder if his patients who continue to smoke would be able to find new doctors. We have a real shortage of GPs to the point where people would be relegated to walk-in clinics if they were to lose their doctor.

For the record, I think smoking is dumb. Why anyone would want to inhale carcinogens (and pay nearly 5 bucks a pack to do it!) is completely beyond me. But I am just sick of medical professionals acting all holier than thou. We all have some bad health habits because we are all human. Get over it. It seems a little childish to say "Either do what I want you to or go away".

mario_ragucci · Mar 2, 2002

JMP - I gahchew the first time. :-) But you can apply this logic to any multitude of self-destructive behaviors. Then again, who am I to say a behavior is self destructive? It's not my place. See?

We didn't start the fire. It was always burning since the world's been turning (B. Joel)

OBNURSEHEATHER · Mar 2, 2002

Originally posted by fergus51
I don't like it. A doctor is supposed to be your guide, not your boss. They're supposed to tell you what they think, but in the end the decision is yours.

How true. Besides, aren't all of our bad habits just job security for them?

Heather

JMP · Mar 2, 2002

Fergus 51

Since when is the idea you should not smoke for the sake of your own health and others around you a moral belief? Dr. Ross is taking a stand that if you continue to smoke.........you had better seek treatment to TRY TO QUIT or seek another Dr. I agree it is a conversal stand.......but God, someone has to do something to try and drive it into people's heads that smoking is one of, if not THE worst thing you can do to your body. Just the fact so many people are now talking about it has had a good effect. People need to wake up for their denial and QUIT SMOKING.

Knowing Canadians in general, I doubt too many others would take the stand he is. I think we are too polite and careful. Smoking needs to be brought out into the sun and exposed for the killer it is. It is not a moral issue in my mind. Abortion is. Smoking is not.

mattcastens · Mar 2, 2002

Kudos to Dr. Ross! I think he doing exactly the right thing. I certainly wish more physicians would follow suit.

MollyJ · Mar 2, 2002

I don't think it is abandonment because of the advance notice. This is how you do these things.

True motivation of health care change is not coercive, patriarchal, or punishment. It comes frome within the client but, I believe, can be encouraged, assisted, supported by the HCP.

A definition of addiction that I like is, "use with loss of choice and control." Nicotine addicts exemplify this excellently because they continue to use nicotine even when they can acknowledge the health harms and how expensive it is to them (monetary and otherwise).

Cognitive dissonance, the state of doing something we know better than to do (ie eat bon-bons, smoke cigarettes, drink the food out of our family's mouth), WILL EVENTUALLY motivate change IN SOME PEOPLE. It will generate denial in others; that's why I hear so many people tell me that their lung disease is BETTER when they smoke OR tobacco helped grandpa live longer.

I also feel that smoking is a (maladaptive) coping mechanism for many. As a nurse, I try to be very careful about saying to people, "Change everything now!" I wouldn't want anyone to say that to me. I am more likely to ask people what "dragons they want to slay first?" That is, which problem (or two) would you like to work on first?

Nurses, beware of saying, "Gee I have problematic health behaviors myself. Who I am to saying ANYTHING to these people?" Our own failings should give us compassion in understanding the frustrations of changing negative health behaviors but they should not prevent us from addressing them with clients. The answer to the question in this paragraph is that you are the client's health care provider and you (or someone on their care team) have an _obligation_ to address problematic health behaviors with clients.

Nurses interested in Health Behavior Change should consider Stephen Rollnick's book by the same name about this topic. It gives pragmatic, research based information on this very topic and is based on a brief intervention model, which is just what nurses have time for. One of Rollnick's co-authors is Pip Mason, a nurse. They are UK authors. The book is excellent and should be parting of nursing school curricula everywhere.

Behavioral change is based on getting to know the client well enough that you start to really understand some of their restraining factors but you must avoid getting into the habit of saying, "Well, you could do this..." to which the client replies, "That won't work because....". Those of you who have ever been on this particular merry-go-round know that it goes infinitely around. Rollnick addresses this.

Rollnick has tested his research in the context of common health behaviors such as smoking, alcohol and diabetic compliance and dietary compliance. Good stuff. Didn't intend this to be a commercial for the book BUT it is available with internet book sellers.

I think this doc is power-tripping and likely to promote long term change in very few.

mario_ragucci · Mar 2, 2002

A definition of addiction that I like is, "use with loss of choice and control."

How many people have the choice and control to stop driving their car everyday? Oh yeah - make that scary face and think I'm a nut. Well, can you not drive your car every day? Are you a closet gasoline addict :-) Come out...it's all right :-)

Do you know how to feed yourself without damaging yourself? Are you in control of your lifestyle? Changing a persons "life""style" is mucho problemo. I remember when not so long ago weed make fun of the "evil communists" because they had no freedoms in their country, so we were told. Stuff that was promoted for the good of all was very communist and unAmerican.

No doubt, breathing in, over and over, carcinogenic vapor off a cigarette is dooming, and nicotine is addicting. We're talking about a person's life here, and whether we want to help them or not. Is it okay to not want to help yourself? If a person can't stop smoking, or driving, or consuming crap, or being sexual, or skydiving, or news reporting, or religious...whatever,,,live and let live.

You can disagree with wanting to treat anybody. It's easy to see the frustration; I'm for "live and let die" as well. We're all headed in that direction, I heard.

All too often, all kinds of people throw all kinds of stones to hide their own hands.

I updated my webpage now, and it includes about 40 .mpgs of me doing everything. Check it out now, funk soul brother.

:kiss

JMP · Mar 2, 2002

Mario

I understand you are not a nurse...... that you want to be one. The live and let live stuff will get you no where in the health profession. As health professionals, we have responsibliltes. Health teaching is one of them. Health teaching actually is a BIG part of our role. WHen and if you do become a RN........you will understand that life is not all sweetness, letting everyone stroll down the old garden path smelling roses. Depending on what part of nurses you aspire to.......well.......when you get there you will understand the pain and agony watching someone struggle for every breath, coughing up blood, gripping the bed rails with white knuckles because they can't get air OUT of their lungs.

In moderation, drinking is OK, eating is OK, hell even driving the evil car is ok. SMOKING in any form is bad. IT KILLS PEOPLE. I have watched it. Before ICU I worked palliative-oncology. If you can't deal with these issues, I would strongly recommend you go into management. Reality, my friend, is what we deal with EVERY day. Especially in an ICU setting.

rncountry · Mar 2, 2002

I currently have a patient right now that is a self mutilater. He started doing this in prision. Currently he is in after he swallowed 15 razor blades a few months back and eventually developed a stoma in his abd. It is very high up so is like an ileostomy and simply pours out fluid. He is noncompliant with not drinking water so that makes it worse. He has substancial erosion around the stoma site because of this. I have a wound manager on him to continuous sx. The only way to keep the huge amount of output off his skin. The area is slowly healing. In the meantime he deliberately removes the wound manager, gets up and slurps water from the faucet regularly. Has pulled out not one, but three CVL's which have TPN running in it, his only source of nutrition needless to say. Is capable of turning in bed without difficulty but will not so got a decubitis as well. First time I took care of this guy was a midnight shift where I had to come in because I was on call and we had a couple nurses out sick. I am normally the wound nurse, but worked as the primary this night. Caught the patient smoking in the bathroom. Removed the cigerettes, the lighter and the air freshner he used to try to cover the smell. In short this is the most noncompliant patient I have ever taken care and is likely one of the most frustrating patients I have ever had. The state of Michigan has paid well over a million dollars to keep this man alive, he is on medicare because he has a mental disability. What exactly his mental diagnosis is I don't know because he has been diagnosed as many different things. I truly dislike having to take care of this man because he does not want to get better. We have tried putting a sitter in the room with him to keep him from self destructive behaviors, after three hours he refused to have her in his room. And guess what he can do that. We can't restrain him because that is against his rights. So he can continue his self destruction in the hospital with two different docs and however many nurses there, and the state pays for it all. I think this is absolutely crazy, rights run amok and over others rights. I know that the two docs he has currently would stop treating him if they had that option, I know the nurses would too. It is all well and good to say that healthcare workers do not have the right to judge their patients, and to the largest extent I would agree. Yet I also believe there are times when we ought to be able to say I can't help you anymore until you decide to help yourself, and let it be. There has to be a point in which personal responsiblity comes in. If a patient is not taking any type of responisiblity for their health, not following medical recommendations, not attempting even to do so when it is ok for the healthcare person to say enough? Or do we not have that right at all?

And while the state is paying thousands with this admission, this time around with my patient, there are thousands of children in my state with working parents who cannot get insurance at work for the cost, yet don't qualify for the my child medicare/medicaid program because they make too much money. And yes, I think that is very wrong. I think it is time for someone with a bit of common sense and some guts to say so. The situation changes when the patient is working to get some control over their health and that is all this physician is asking. That the patient participate in their own healthcare, and I don't think that is inappropriate to ask for.

fergus51 · Mar 2, 2002

JMP

I can't agree more that health teaching is a very important part of our job. But that's all it is- teaching. In the end people have the right to do what they choose regardless of how frustrating it can be for us. I don't like the idea that we will abandon them if they don't try to do what we tell them to (and it probably is abandonment if Manitoba is as short of doctors as we are).

And why has smoking become the whipping boy? Why can't we abandon all our patients who are non-compliant? If you can tell me what the difference between a smoker and an alcoholic and a 300 pound fifty year old diabetic eating cake and not taking his insulin or blood pressure meds is I would be a lot more sympathetic to this point of view. It just pisses me off because it is inconsistent. If we stopped treating people whose behavior has contributed to their illness we wouldn't have any patients left.

I think the decision to quit treating someone for their choices is forcing your beliefs on them, perhaps morals was the wrong word. I have also seen firsthand what smoking does. My own mother has had tumors in her bladder five or six times (this is after she had a hysterectomy because of ovarian cancer). I am not blind to that. I am also very aware of the fact that she never succeeded in quitting until SHE was ready. She tried to quit for us, for my dad, for her mom. It never worked, until she did it for herself.

ps

My being Canadian or polite really is not the reason I would continue to treat smokers;)