Frustrating situation

[mappers]

We had a patient last week that was in a no-win situation. She was in her 40's and came to us with a Dx of "Failure to thrive". She was emaciated, weighed less than 80 lbs, covered in sores, weaping legs...terrible. Her feet looked cyanotic. The charge nurse thought she might not make it through the night.

Fast forward to several days later (Tueday) when I come back on shift. She is still there, apparently refusing meds, an IV, refusing dressing changes to her legs, plays with her food, always something wrong with it etc. She has made statements that her boyfriend was trying to poison her, refuses to get in bed, stays up in a chair, incontinent, etc. She is A&O x 3 though. Definately a lot of MH issuse going on. I'm hearing this through the grapevine since she isn't my patient. I finally get her on Thursday and she actually takes a few pills and lets me dress her legs. She lets us get her to the BSC.

The dr. comes in and is mad the she is still here. She's been discharged since Monday and they've been trying to find placement for her. We have a team that evaluates for suicidal/homicidal stuff, but they've seen her and said she doesn't qualify for any type of MH placement. I guess not for a 72-hour hold at least. She has some family who refuses to take her or do anything for her. The SW has talked to NH and has one that says she qualifies, but the SW wants them to see her because she doesn't want to be accused of misrepresenting her status. We have a snowstorm that day and the NH person never shows up.

Get her again on Friday. The NH lady shows up and I'm not sure of the results. Either they accepted her, but she refused to go or they didn't accept her. The next thing I know the SW (who is not our regular one and doesn't know her) says she's going home. She lives with her brother and he'll care for her. (First time we've heard of a brother.) Ambulance shows up at shift change to transport and she refuses. I ask hef if her brother is home and she says no. Charge nurse calls family and only brother is in jail. Plus she probably had her electricy cut off at her apartment. Did I mention we'd had a snow storm? Can't send her out now.

Apparently she went to the NH the next day. But what went horribly wrong??? Why do people like this slip through the cracks? APS had been called early on and had a long history with her. What else could have been done for her? She needed to be in psych hospital, but with her medical issues, I'm not sure anyone would have taken her.

We've had other patients where no NH will take them and family won't take them and they just "live" at the hospital for weeks. It's so sad and frustrating all at the same time. What do other countries do? How can we fix this?

[canoehead, BSN, RN]

I've seen many situations where the patient retains the right to choose, but they aren't making logical decisions. So they refuse the people/places that can help them and request to go home (with the power shut off), or want to stay in hospital (where they know the routine). The hospital cannot discharge them somewhere inappropriate, and can't force them to go anywhere. They certainly wouldn't be accepted anywhere if they were forced anyway. Usually with time and constant negotiation they get browbeaten into the 3rd or 4th choice place. /if they have family that cares about them the family can usually say "look, you're going!" and threaten to withdraw cigarettes or visits to make them agree. Nothing I've seen is ideal.

[Virgo_RN, BSN, RN]

The chronically mentally ill are an underserved population in this country. There simply aren't enough resources available to help them. It is unfortunate, really.