How to handle inappropriate pt behavior in Home Hemo?

[starbin, BSN, RN]

Our home hemo program is based in nursing homes. I had problem with one patient today. He is a Nsg Home resident, very alert and oriented patient, walks to dialysis suite (meaning needs minimum to none assistance for personal care). We had been having issues with this patient's schedule. He comes down to dilaysis 1.5 hrs to 2 hours late. Last treatment, the nurse had offered him to change his schedule to the afternoon shift if coming in the morning was a problem for him. He had said he will think about it and let us know. So, when he came down 1.5 hrs late today, I asked him what he thought about going to the afternoon shift. He became very hostile and screamed- "No". Then I reminded him that he is 1.5 hrs late for his schedule. He started yelling, cursing, and called me, "*******immigrant ********". I told him, his behavior is inappropriate, he became further aggressive and used the "**** you" at least five times. I kept reminding him his behavior was inappropriate.

How do I handle this situation? I know this behavior should not be tolerated, and other patients were also listening. If we tolerate these behaviors, it only reinforces the behavior on not only him but other patients as well.

I will talk to the Social worker about it. But don't know if that will help.

Please share your opinion and experience.

[happybunny1970]

Wow. I work Acute, so I don't know what they do in outpatient... Have you talked to anyone in an outpatient clinic about what they do when a patient consistently comes in late? Seems like his should be handled in the same way. Being that there's such a high volume of patients at any facility, and scheduling is so tight, and the profit margin that allows the facility to continue to run is ALSO very tight...

It sounds cruel, but can this guy be 'fired' from your unit and forced to transfer to a traditional outpatient unit, where he would have to travel by arranged transportation?

His behavior not only affects the other patients as you've stated, but also your bottom line by causing the staff to work late and under stressful conditions (ie: hostility). Perhaps his Nephrologist should be contacted -- maybe the doc can either: a) talk sense into the guy (our docs are good scolders!) or b) check him out for some medical mental problem that requires medication or other treatment.

[traumaRUs, MSN, APRN]

He either needs a behavior contract with enforceable consequences or he needs to be moved to an outpt facility that can deal with his behavior better. You don't have to tolerate this.

[starbin, BSN, RN]

Thanks both of you. The guy apologized to me before he left the unit. I discussed his behavior with the social worker, and she assured me that she will talk to him about the behavior.

I don't work on his regular dialysis days (except for every other saturdays), so don't really know if something changed. i will update on how things go.

Having this guy transferred to another facility is next to impossible. The nursing home tries everything possible to hold onto the patients, I will give you an example:

I have a patient who always requests to cut her treatment half hour short. Talked and explained to her the consequences zillion times, the MD knows very well. Every time she wants to get off the machine she will say my stomach is aching or my something is bothering, I am in pain (she has a stage 3 sore on her rear, so the pain is understandable but refuses the pain pill when offered) or something else. If not ended the treatment right away, she will call her son (she has a cell phone hanging around her neck), and the son will call the unit at lest five times with the same question-"Is my mom alright? Will she be ok? Did you call the doctor? why don't you take her off?". I am monitoring the patient, vital signs are very good, no non-verbal sign of distress other than the verbal expression of not feeling good. What do I call the doctor for?

I thought i must respect the patient's and the family's wish to terminate her treatment early, so I let her go 30 mins earlier. Within half an hour, I was visited by the Nursing home's some patient services director or somebody, and was told that I shouldn't let the patient cut her treatment short because if the patient consistently does so, the family will move the patient to some other facility and they will lose their business. I told him that it was the patient's as well as the family's request to let the patient go, and as a nurse it is my responsibility to respect the patient's right to deny treatment. He kept insisting that both the patient and her son are -NEGATIVE. I don't know what he meant by that. He agreed to come to the dialysis unit and talk to the patient each time the patient wanted to come off the machine early.

My point is, the NH has a big fear of losing their patients. There is no way they will transfer anybody out just because of their behavior. Every now and then we get these kinds of patients here, the NH doesn't kick them out but the patients/families themselves keep fishing around from one NH to the other. I hope this man will also find some other place for himself.

[Natkat, BSN, MSN, RN]

I have a patient who always requests to cut her treatment half hour short. Talked and explained to her the consequences zillion times, the MD knows very well. - snip - I thought i must respect the patient's and the family's wish to terminate her treatment early, so I let her go 30 mins earlier. Within half an hour, I was visited by the Nursing home's some patient services director or somebody, and was told that I shouldn't let the patient cut her treatment short because if the patient consistently does so, the family will move the patient to some other facility and they will lose their business. I told him that it was the patient's as well as the family's request to let the patient go, and as a nurse it is my responsibility to respect the patient's right to deny treatment. He kept insisting that both the patient and her son are -NEGATIVE. I don't know what he meant by that. He agreed to come to the dialysis unit and talk to the patient each time the patient wanted to come off the machine early.

My point is, the NH has a big fear of losing their patients. There is no way they will transfer anybody out just because of their behavior. Every now and then we get these kinds of patients here, the NH doesn't kick them out but the patients/families themselves keep fishing around from one NH to the other. I hope this man will also find some other place for himself.

I would tell the nursing home that keeping a patient on dialysis once they have asked to come is patient abuse and false imprisonment. You CANNOT leave them on if they want to come off. Your loyalty is to your license and your own integrity, not to the nursing home.

Once the consequences have been explained to them a few times, they know the deal. Just document every time this happens so if problems do come up from cutting their treatment, it has been documented and they can't accuse you of taking them off for your own convenience.

This is fairly common. Some patients come off early all the time and it doesn't affect them. Others become fluid overloaded and wind up in the hospital, and then they understand that what you are telling them is for their own good. For those patients, they are usually compliant for a while, then backslide into coming off early and the cycle repeats itself.

I do my best to convince them to continue treatment, but if they continue to insist on ending treatment early I figure it's their responsibility now.

People are people and you can't change them. Some dialysis patients are negative and you will drive yourself crazy if you let it get to you. Let them be. I cope with the negativity by talking with the patients, getting to know them, letting them know I respect who they are as individuals (even if I secretly despise them), and gain their trust. Once I get their trust I can sometimes get them to cooperate - but not always. And if they don't cooperate, so be it. If I can't reach them despite my best efforts, I just do my job and pretty much ignore them.

In my opinion the NH insisting that you do things their ways is like an annoying mosquito buzzing around my head. I'd brush it off. They would have to work pretty hard to prove to me or anyone else that they chose a different nursing home because of their dialysis treatment. There are probably a lot of things that happened that made them change. Saying it's dialysis treatment is just looking for an excuse; someone to blame other than themselves.

Good luck.

[starbin, BSN, RN]

I would tell the nursing home that keeping a patient on dialysis once they have asked to come is patient abuse and false imprisonment. You CANNOT leave them on if they want to come off. Your loyalty is to your license and your own integrity, not to the nursing home.

Once the consequences have been explained to them a few times, they know the deal. Just document every time this happens so if problems do come up from cutting their treatment, it has been documented and they can't accuse you of taking them off for your own convenience.

This is fairly common. Some patients come off early all the time and it doesn't affect them. Others become fluid overloaded and wind up in the hospital, and then they understand that what you are telling them is for their own good. For those patients, they are usually compliant for a while, then backslide into coming off early and the cycle repeats itself.

I do my best to convince them to continue treatment, but if they continue to insist on ending treatment early I figure it's their responsibility now.

People are people and you can't change them. Some dialysis patients are negative and you will drive yourself crazy if you let it get to you. Let them be. I cope with the negativity by talking with the patients, getting to know them, letting them know I respect who they are as individuals (even if I secretly despise them), and gain their trust. Once I get their trust I can sometimes get them to cooperate - but not always. And if they don't cooperate, so be it. If I can't reach them despite my best efforts, I just do my job and pretty much ignore them.

In my opinion the NH insisting that you do things their ways is like an annoying mosquito buzzing around my head. I'd brush it off. They would have to work pretty hard to prove to me or anyone else that they chose a different nursing home because of their dialysis treatment. There are probably a lot of things that happened that made them change. Saying it's dialysis treatment is just looking for an excuse; someone to blame other than themselves.

Good luck.

Thanks a lot for the supportive words. I had the doctor change the patient's dialysis time (half hour shorter now), and also had the doctor write- "Ok to terminate treatment early if the patient verbalizes difficulty to stay on treatment." The patient has been compliant to her treatment time since, and she is doing fine so far.

[Natkat, BSN, MSN, RN]

Thanks a lot for the supportive words. I had the doctor change the patient's dialysis time (half hour shorter now), and also had the doctor write- "Ok to terminate treatment early if the patient verbalizes difficulty to stay on treatment." The patient has been compliant to her treatment time since, and she is doing fine so far.

I'm glad the situation has a happy outcome......for now. She may act up again over some other issue later, or push for an even short treatment.

It's a thing with dialysis patients to try and control everything about their treatment. If you can find things that they CAN control safely without affecting their health, I usually try to steer them in that direction. If they have to have a certain number of pieces of tape, a certain blanket, or whatever, I try to go along with what they want. As long as it doesn't interfere with the care of other patients - for example, insisting that they always have a certain chair when we have to be more flexible with who sits where - I go along with it. I found it's so much easier to just do that little teeny thing that they want than it is to spend several hours arguing over it.

Hang in there.

[starbin, BSN, RN]

I'm glad the situation has a happy outcome......for now. She may act up again over some other issue later, or push for an even short treatment.

It's a thing with dialysis patients to try and control everything about their treatment. If you can find things that they CAN control safely without affecting their health, I usually try to steer them in that direction. If they have to have a certain number of pieces of tape, a certain blanket, or whatever, I try to go along with what they want. As long as it doesn't interfere with the care of other patients - for example, insisting that they always have a certain chair when we have to be more flexible with who sits where - I go along with it. I found it's so much easier to just do that little teeny thing that they want than it is to spend several hours arguing over it.

Hang in there.

Yes she has started already. She has fistula on one arm, PICC line on the other arm, is left AKA, the only limb we can take her blood pressure is the right leg. She almost jumps off the chair while taking her blood pressure. And unfortunately, it always have to be repeated or longer than usual because she is moving her leg so much.

We are trying to help her by only tying the cuff when taking blood pressure, and releasing it immediately after......but as you said, this is probably her coping mechanism, trying have control over the situation, and probably the leg hurts a lot because it hasn't been used for a long long time.....

[GeauxNursing]

I thought i must respect the patient's and the family's wish to terminate her treatment early, so I let her go 30 mins earlier. Within half an hour, I was visited by the Nursing home's some patient services director or somebody, and was told that I shouldn't let the patient cut her treatment short because if the patient consistently does so, the family will move the patient to some other facility and they will lose their business. I told him that it was the patient's as well as the family's request to let the patient go, and as a nurse it is my responsibility to respect the patient's right to deny treatment. He kept insisting that both the patient and her s

you are correct. it IS the patient's right to come off the machine. (however frustrating it is for us.) does this patient sign an AMA? there is nothing else we can do. that is terrible of your facility to bully you for respecting a patient's rights.

keep sticking up for yourself; can u speak to your DON?