noncomplian patient...what to do?

[chenoaspirit]

I have a patient with A-fib, venous insufficiency, MASSIVE venous ulcers on her legs, and rotting fingers. I make twice-weekly visits to change UNNAs boots. She is supposed to elevate her legs, wear oxygen at night, wear her unnas boots. When I go for my visit, she has taken off her unnas boots, she hasnt worn her oxygen and she REFUSES to elevate her legs, stating that elevation makes them hurt. She wont go to her MD appts, she complains all the time. Now her fingers are literally ROTTING off her hand. They are black! Her body is oxygen depleted all the time. I have done teaching over and over and over, explaining the importance of wearing her oxygen and being compliant. She hates the unnas boots, which Im sure I would too, but I keep telling her that her legs will end up infected or amputated if she continues to be noncompliant. Im tired of arguing with her, Im tired of "wasting my time" by doing all this wound care and teaching and blood draws, etc. I love all my patients and want to help them all, but she is unwilling to do anything to help herself. I want to just stop going because the visit exhausts me, but I wouldnt be able to live with myself. Ive talked with the doc, he feels the same way I do, but what do we do? I document carefully. I walked in her house Thursday and she was asleep in her recliner, legs not elevated, no oxygen on, her O2 sat LOW. I woke her up and showed her what her O2 level was, she didnt care. What would you do? Her response was "I can only do what I can do". Well she isnt doing ANYTHING! Please give me advice....

[chenoaspirit, ASN, RN]

Thanks guys for your advice. I really appreciate it. I'll update soon on how things are going and what happens. I just dont understand people like this. Its so nice to have you guys to share things with and ask for advice. You guys are great!!!

[lamazeteacher]

OK, Y'all. You've stated what hasn't happened, what the patient needs to do, but obviously hasn't accomplished for no apparent reason.......

I saw what you did and what the patient didn't do - what did the patient say? One was doing the "best I can". Try to find out what their "druthers" are. What their lives would be like, if not for the restrictive condition in which they find themselves. Put your Psychiatric Nurse hat on......

ACTIVE LISTENING will reveal the things patients think are meaningful to them, and use them as the hook to get them to want recovery. Anyone who doesn't recover (unless they're moribund) hasn't found a reason to do that. That means that they have become very, very depressed!

The op's patient really doesn't care to live, and therefore by definition, is suicidal !!!

She is beyond a MSW's ability to treat/reorganize priorities. She needs a psychiatric referral, to get on antidepressants (which she may not take, unless her HH nurse helps to hook her reason to live). Not the nurse's reason or the granddaughter's reason - her reason. The role of the HH nurse, is to get that referral. Certainly her behavior is aberrant enough to get one:

"Patient refuses O2, will not wear UNNA boots, and resists all teaching regarding the reason for those therapies. She refuses to accept a nutritive diet (if that's so, which I think may be), preferring (whatever junk she will eat, or booze)." You can add missed meds and whatever other self destructive things you've found. FIGHT FOR HER LIFE!!!

She also needs physical therapy for her poor oxygenation in her hands. They have great equipment that can be used in the home, for stimulating circulation. Their evaluation is very helpful. Since her doctor hasn't had a consult with a cardiovascular physician, you can suggest that, too. It's important that you conference with those people about keeping a united front regarding the hook you find to keep her involved in their treatment regime.

She does need you (you're her lifeline, which means she still does have a foot on this earth), and since you tolerate her negativity better thyan the other nurses at your agency, chenoaspirit, it's up to you as HER choice for her case manager, to find the "HOOK", TO HER REASON FOR LIVING.

Ask her to tell you what turns her on in this world, (without giving away your need to show her she really wants to live), when you're both sitting eye to eye. Be patient, not exasperated as she won't give much away the first or even third time (obviously), so rephrase your question until something meaningful comes to light. use one question each visit, and don't take "nothing" for an answer.

Here are some other examples of nonjudgmental open ended questions:

"I'd like to get to know you better. What do you think after, or just before opening your eyes each day?" Whatever she says is just fine. Thank her for considering an answer.

"Before you became so sick, what gave you some enjoyment in your life?"

If you know what his/her occupation was, ask how it became apparent that he/she wanted to do that.

Since the granddaughter is in the picture, she must have had a child. Ask her what she enjoyed about having a child, or thought others enjoy about that.

It's OK to wait in silence for her answer. For heaven's sake don't give her your answers. Respect her individuality, and let her know that you do. "We're all different. Your experiences are different from mine", might get away from any appeal for your opinion. Keep redirecting this casual, gentle conversation back to her.

Be sure to compliment any response you get! e.g."That was hard to say, thank you for your good work".

I notice that nurses can be quite punitive reacting to patients who don't fall in step with their own values. AVOID THAT!!! Even the suggestion that hospice might be necessary for her, and especially taking her off the agency's case list, are rejecting, hostile ways of handling fragile people who are at a crossroad in their lives, that may seem like their last crossroad. Hospice is not a dumping ground for difficult patients! Most of their work involves arrangements for death and pain control (not necessarily in that order).

As far as the pain she says she experiences when her legs are elevated in UNNA boots, get an order for analgesia with synergizing light anxiety relief medication, for that. Nothing too heavily sedating, so she'll sleep at night.

Please post what you find when/if you act on the above suggestions. I sure hope you'll hang in with her, without making her cooperation your "raison d'etre".

[jarymo]

not only is this patient non-compliant, but she is a legal risk to your license and the company you work for. Your manager should have known about this long ago if no other nurse will do for this patient. If your patient is not depressed and is of sound mind, inform her that you will no longer be making home health vists because of her refusal to particapate in her own care. Mabe she wants to be discharged. I'm frankly flabergasted that medicare and your company has cont'd to pick up the tab on a patient that is non-progressing and non-compliant , squandering supplies, etc..have her sign the Bippa and get out, and put her on your "don't take list".

[lamazeteacher]

not only is this patient non-compliant, but she is a legal risk to your license and the company you work for. Your manager should have known about this long ago if no other nurse will do for this patient. If your patient is not depressed and is of sound mind, inform her that you will no longer be making home health vists because of her refusal to particapate in her own care. Maybe she wants to be discharged. I'm frankly flabergasted that medicare and your company has cont'd to pick up the tab on a patient that is non-progressing and non-compliant , squandering supplies, etc..have her sign the Bippa and get out, and put her on your "don't take list".

Addressing the issues herein that I've enboldened: every patient is a legal risk to our licenses and agencies for which we work. Running away scared is not pertinent or wise in this situation, in my opinion. I've worked at home health agencies for almost 2 decades, supervising nurses (we aren't called "managers", other than "case managers"). That's why good malpractice insurance is a must for all nurses. I haven't known any facility or agency in my 50 years of practising nursing, that has a priority of discharging patients lest they sue. When you work alone out in the field your instincts, knowledge, plan of care and professional ethics, and concern govern your actions, not fear.

Most patients are depressed to some degree when they're sick for more than a week or two. Most of them are of "sound mind" even when exhibiting antisocial characteristics. Let a psychiatrist determine her state of mental health, and go on that. Your raising the possibility that this patient "wants to be discharged", is pretty far fetched and would fit if she consciously intended to commit suicide. I don't think that's the case here. She would have done that, if it was clear to her that she wanted to end her life.

The patient chose a very generous, kind nurse for her care (although it could be that this nurse is the only one kind, caring and brave enough to take on this patients' needs). That means that she is accepting that person who has worked so hard for her survival. It's a hopeful sign.

The last thing that should bother any ethical professional is the cost of treating someone who possibly may not survive. That's as fatalistic as saying anyone with a disease in its late stages, decubs need not be treated. When Hospice was started, despite Dr. Elizabeth Kubler Ross's objections, only those patients who agreed to give up and not have treatments, were considered for that type of care. Wiser practitioners have dropped that stance.

I think you meant HIPPA, but wrote Bippa. HIPPA is signed at the first home visit; and its main purpose is to allow insurance companies to communicate with care providers to determine if they'll cover the bills, or continue to insure patients.

Home Health agencies don't keep "do not take" lists, although they do remember patients who presented difficulties for the staff. I took care of one of those patients for years, with great success in the face of many psychosocial factors.

Sometimes it's necessary to act "as if" the patient wants to survive, even in the face of their opposing viewpoints. That takes an experienced well educated nurse who knows limits, boundaries, and "best case" scenarios.