Hostile and demanding patients. How do you handle them?

[Virgo_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?

[Ms Kylee]

I kill them with kindness.. it always works. I have had them talk my ear off, so I usually back out with a kind "I need to go check on my other patients, but I'll be back later". That seems to take the rudeness and hostility right out of them.

[AngelfireRN, MSN, RN, APRN]

If a calm, rational explanation has been tried and has failed, I resort to the oldie but goodie. "I am not going to tolerate your behavior. When you are ready to act like you have sense, I will be happy to discuss this matter with you. You may call me then."

Seems harsh, but has not failed me yet.

[leslie :-D]

AngelfireRN said:

If a calm, rational explanation has been tried and has failed, I resort to the oldie but goodie. "I am not going to tolerate your behavior. When you are ready to act like you have sense, I will be happy to discuss this matter with you. You may call me then."

Seems harsh, but has not failed me yet.

I agree with these tactics, angel, but I do not agree that they are harsh.

I am no different personally than I am professionally.

in either situation, if someone is hostile/rude and is not receptive to civil discussion, I have no problem in setting limits.

if someone perceives that as harsh, that is their problem.

being polite yet assertive, is a perfectly reasonable response.

leslie

[AngelfireRN, MSN, RN, APRN]

Thanks, leslie.

The reason I said it may sound harsh is that I am a very outspoken, assertive person, and sometimes people take it the wrong way. I have learned from bitter experience not to be a shrinking violet when it comes to this type patient.

[socalpca]

Patient: blah, blah, blah, some unreasonable request.

Me: We will be happy to help you, but right now you have already had all the pain medication I can give you right now. If you will return to your room, we will be able to talk further when I get there.

Basically, I tell them that PRN doesn't mean scheduled and just because it's been two hours, that doesn't mean that you will get that medication every two hours....especially if I notice you sleeping/passed out. If the patient becomes unreasonable/loud/abusive, i tell them that their behavior is not helping their situation and that this outburst of energy shows me that you are feeling better and not in need of more medication.

[leslie :-D]

socalpca said:

Basically, I tell them that PRN doesn't mean scheduled and just because it's been two hours, that doesn't mean that you will get that medication every two hours....especially if I notice you sleeping/passed out. If the patient becomes unreasonable/loud/abusive, I tell them that their behavior is not helping their situation and that this outburst of energy shows me that you are feeling better and not in need of more medication.

while I can respect one's ways of strategic redirection, an outburst of energy does not mean one is feeling better.

rather, any outburst of negative emotion, can indeed indicate escalating pain, anxiety or any other type of discomfort...

and often does indicate the need for more pharmaceutical intervention.

not always, but certainly often.

leslie

[meownsmile, BSN, RN]

I guess as a last resort you could always explain what Narcan is and what it does and how it will affect their care. That you dont want to use it but if they slip below a safe level of conciousness you will have to give it to them and then they will not be able to get anything for pain for a lengthy period of time.

[UM Review RN, ASN, RN]

meownsmile said:

I guess as a last resort you could always explain what Narcan is and what it does and how it will affect their care. That you don't want to use it but if they slip below a safe level of conciousness you will have to give it to them and then they will not be able to get anything for pain for a lengthy period of time.

Thanks for the reminder! I have given that speech also. A couple of the patients were as familiar with Narcan as they were with their pain meds.

I know that it's annoying to some of us, but to me, to see any person get to the point in his/her life where they're so desperate that they'll lie, cheat, or steal, go homeless and without human relationships just to get that fix, whether or not it was brought on willingly or not, is just plain tragic.

[nyapa, RN]

gonzo1 said:

Homeless people often have multiple mental health issues. What I do with these patients is try to not take their behavior personally.

True, but that is no excuse for treating ppl - yes, nurses are actually PEOPLE - in an inappropriate, rude, and aggressive manner. I like what the others have said. Treat them like you would any other patient, and if they continue to treat you badly then tell them you will return later, when they choose to treat you with respect.

With regards to medication, I have at times taken the med chart, or the computer to the patient to show them when medications have been ordered, and when they are due next. Then I explain that if it is not satisfactory, that when he sees the doctor on his next round, he discusses the situation with him.

Then of course, document...

[Sabby_NC]

Hostile and demanding patients. How do you handle them?

With Care.

You never know which way they are going to go.

For some reason I like handling difficult patients. I like to get to the bottom of their behavior and actions.

I always will speak with the Doctor if their pain medication is not holding them for as long as it should. Sometimes we just need to add an adjuvant to the opioid to calm or settle the patient down.

Take care and continue giving them the care they all need and deserve without any prejudices getting in the way. Yes it is hard but we are better than that eh?

[jlcole45]

I too kill with kindness (but not above what I do for other patients) and if doesn't work,

I get very stern and set clear limits, repeat it as many times as necessary, and

take in a witness if I am at all worried about legal, ethic or safety issues.

He obviously has major issues - I can't even begin to imagine walking in his shoes.

[socalpca]

earle58 said:

while I can respect one's ways of strategic redirection, an outburst of energy does not mean one is feeling better.

rather, any outburst of negative emotion, can indeed indicate escalating pain, anxiety or any other type of discomfort...

and often does indicate the need for more pharmaceutical intervention.

not always, but certainly often.

leslie

True, but most of the unreaonable patients I care for don't know that.