Hostile and demanding patients. How do you handle them?

[Virgo_RN, BSN, RN]

My recent experience with a hostile and demanding patient got me thinking of ways I can improve the way I handle these patients in the future.

This patient was a homeless man with a history of chronic pain, uncontrolled diabetes, COPD, and MRSA, currently being worked up due to his presentation in the emergency room with complaints of dyspnea and abdominal pain. The man is getting every diagnostic under the sun, and is on scheduled and PRN pain medications.

He is rude and demanding. Constantly on his call light and will come seek out his nurse to demand pain meds. Accuses staff of lying to him and withholding his pain meds. Doesn't even know what medications he is on for other conditions, but thinks he knows what time he gets pain meds. When he thinks nobody's looking, the man has a RR of 8, but as soon as he knows someone is looking, of course it's 16. So, we try to explain to him that the PRN medication is not *scheduled* for every two hours, but that two hours is the minimum amount of time we have to wait between doses, and that if he is too sedated, we cannot give him more. He insists that he is supposed to get the pain med every two hours. In the meantime, he is nodding off in bed.

How do you reason with someone like this?

[TheCommuter, BSN, RN]

NancyNurse08 said:

How do you reason with someone like this?

It's simple: you can't.

You cannot effectively reason with an unreasonable person. Attempting to do so will only waste the time of all parties that are involved.

[TheCommuter, BSN, RN]

As for dealing with hostile patients, professionally and respectfully inform them, "I will not tolerate your behavior at this time, so I'll return to your room when you are ready to receive care from me. Excuse me, but there are currently other patients who are willing to receive services."

[Medic/Nurse, BSN, RN]

rapid sequence intubation.

splits the cords, optimizes oxygen delivery, eliminates vocal elimination!

just kidding. does kinda make you wonder why they would treat you this way - could they be hypoxic??? no. I think that some folks are just mean. (but, they don't need an ett to prove that!)

there, I said it --- mean. mean. mean.

handling them???

I don't think there is a good way.

I like the commuter's answer - can't let 'em treat you like that. plan. expectations. goals. ahhh!

good luck.

[locolorenzo22, BSN, RN]

You know, many of the s/s you describe sounds to me like illness and demanding patient who is used to getting whatever he wants, because he wears down the staff....

You can only calmly explain what you are stuck doing, and say, "well, if you don't like it, there's the door."

I often have demanding patients who don't seem to understand that my priority is feeding the DD guy in 1, and the confused patient in restraints in 12, and finding you a cup of coffee is wayyyyy down there at the moment....

I kill em with kindness, and explain the same things over and over...might be more effective if I just had a tape recorder....

[TheCommuter, BSN, RN]

locolorenzo22 said:

You can only calmly explain what you are stuck doing, and say, "well, if you don't like it, there's the door."

If I could get away with it without any consequences or disciplinary action from management, I'd tell all of my abusive and demanding patients that "You have other options and if you don't like our facility, you are free to pack up and go to another place. I'd really wish you'd seriously consider this option."

[gonzo1, ASN, RN]

Homeless people often have multiple mental health issues. What I do with these patients is try to not take their behavior personally. Of course we can't give them more meds than they are scheduled for so I use "stuck record" method of communication. Just keep repeating in the same calm voice "Per the doctors orders I can't give you anything at this time"

Also, homeless people lead very isolated lives so they may be demanding because they are trying to facilitate interaction with you and they know that you can't walk away from them because you are being paid to be nice, and take care of them.

I try to keep them fed and watered and comfy with warm blankets. After that the only choice is letting them leave if they want to.

Just be careful when you are in their room because sometimes they (actually, any patient) can become suddenly violent. Try to stay arms length away, and a clear path to door. Keep door open in case you need to call for help for any reason.

These patients are very hard to deal with but I try to kill them with kindness and that seems to usually work.

When all else fails I try to remember to tell myself that I might be the last human they have contact with before they die because living on the streets is dangerous and most of these people have bad health problems that we tend to trivialize because they don't take care of themselves and are not considered productive members of society.

[UM Review RN, ASN, RN]

OK, I have to warn you that this does not always work, but here goes:

That type of patient is isolated and homeless because of his addiction. The fear of being in the hospital and having a somatic illness can also make a patient rude and more difficult to deal with than he would be at baseline (and this guy sounds like an antisocial type with zero social skills anyway).

I always figure that with guys especially, the rude, mean front is just that -- a front. They're scared, they're insecure, and they know you don't like them. They know they're social outcasts. The question is, do we need to reinforce that self-image by treating them badly or do we have enough compassion and are we secure enough in our own psyches to look past the addiction, the manipulation, the defense mechanisms, to see the person -- the suffering person -- underneath?

So I try to engage them in their care by asking them exactly where it hurts, when it started, and what types of medications work for them. When they feel that I'm really listening to them, then I can start teaching them about why a certain medication was not prescribed or why it's not working. They usually believe me when I tell them that I will do everything possible to take care of their medication needs, because I mean it.

I've come to the slow realization that we're a hospital, not a detox unit. I'm not interested in curing the addiction, only managing it.

If one med isn't working because it's decreasing respirations, maybe a pain management consult is in order. If the patient is trying to use the docs and me to commit suicide by prescribed medications, the patient gets the "bottom line" talk -- "Bottom line, we cannot medicate you if X, Y, and/or Z happens because you will die. End of discussion."

Of course, as soon as there's a problem with a patient seeming to want to be overmedicated, we get a psych consult.

But overall, I try to set boundaries for behavior and I try not to react when they're upset and trying to manipulate, and if all else fails, they get the Bottom Line speech. What they do with that information is completely up to them. I've had many people respond positively, and a few who went AMA, but I know, whatever else happens, that we did our best for them.

[purplemania, BSN, RN]

Do not be alone with him if at all possible. Witnesses and good documentation are necessary. He is an angry person and may take it out on you physically.

[maelstrom143]

Kill them with kindness. I ensure a complete and accurate picture of the pain and document it at the beginning. I let the pt know, before he asks, about his pain med, how often it is allowed, and that per facility and pcp protocol, I am not allowed to just bring it to him, so he must ask me for it, but that I will try to keep an eye out for him and be available as time permits. If the first thing the pt does is ask for pain meds and I know he has just received them, I inform them that I will check on times and get it to them as soon as able to and as time permits. I ensure he has drink &/or food (within the dietary boundaries allowed). Often, when caring for them, I will ask questions and get them talking about what they love. Other times, they prefer to be quiet and I respect that. I always smile. If they behave inappropriately, I will let them know that I am willing and able to care for them and will do my best, but I must have their cooperation and that my main purpose is to get them back to feeling better. This has always worked, even with a paranoid schizophrenic man who, at first, had threatened to kill me upon admission to our unit.

Also:

• Ensure to always have a CNA nearby when in a room with a pt who has psych issues, whether diagnosed or not...you will know. That way, there is always someone nearby to help you, if needed.
  
• Always keep the room door open and a clear path to the door for a quick getaway.
  
• Never give your back to these patients.
  
• Never allow your head to dip below the bed without being able to visualize the pt's actions.
  
• Always treat them with respect and never take their actions or words personally. When on duty, it is all about our pts. Besides, not getting a reaction from you will often diffuse the situation.
  
• Never speak of them as if they are not there. This infuriates them and I have seen many a staff member who has been hit and has no idea why after having done this.
  
• Never have sharp objects near them or leave them in the room.
  
• Never force care on them. Respect their wishes and chart accordingly. Not only is forcing care upon a pt considered abuse, it also excacerbates mental issues and anger.
  
• Never argue or tell a confused or disoriented pt he is wrong. Reorient him in a calm manner. Let him know that it is often disorienting to be in a hospital and ask what you can do to make things more comfortable.
  
• Never be condescending.

These are the things I try to do with all pts, but especially with the elderly and homeless, as they are more likely to be confused and disoriented. I hope this helps.

Now, difficult family members are another ball of wax. They are the ones who usually drain the energy out of me...oh, well.

[FireStarterRN, BSN, RN]

You can't reason with such a person, he's probably mentally ill.

Every hostile patient is different, some are just mistrustful and stressed out and will respond to kindness. I have good success with explaining everything I do in detail. I'll see the hostile patient and their family visibly begin to relax and feel comfortable.

I'll do the same thing with social rejects like your patient. They really appreciate being spoken to as if they are intelligent, middle class, normal people. There are some people, however, who are unreachable.

[tresamigo]

In view of his COPD, I'd get an order for a pulse ox.

A pain consult would be good.

Many of the homeless have other substance abuse issues, and his liver may be in "high gear".

For those hostile individuals, patients, or family, that are going to come back and haunt you later, I have a chaperone, document the circumstances, and give management a "head's up".