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How to handle patient’s threats

NurseChester88 specializes in Medical Surgical.

Hello everyone, 

I am new to this wonderful platform. I would like go have your feedback or advice about how to deal with patients’ threats.

In my almost two years of nursing experience, I didn't know how upset patients can get if their pain is not treated and care for appropriately in their own terms. But sometimes, I get patients who say things like ”I want IV push meds only”, ”the oral meds don't work on me, IVP meds work faster”, ”nurse, if you don give me IV pain meds, I am leaving! That's it! I can take better care of my pain at home”.

I always offer non-pharmceutical pain management first: ice or heating pads, elevation, etc, then pain medication. I also explain to my patients that I will Inform the provider about the pain not being well managed with the PRN Tylenol and I assure patients that my hands are tight about medication prescription and drug of choice for them. That I Have limitations withing my scope of practice and I am doing my best. 

Most patients apologize, and state they understand me and feel sorry. I can empathize with people and trust my patients when they are in pain and ask many qusriin about their pain (hint; OLD CART).

But sometimes, It is not easy to deal with people who are demanding specific meds and medication routes. 

How do you deal with these patients who threat to leave if I don give them the medication they want and get upset and sometimes nasty?

Background info: I work in a Med-Surg floor on evenings. 

Thank you in advance for your input! 

1. follow up with provider/ follow pain escalation protocols if your facility has them. If that doesn't work?

Let. Them. Leave.

You will never appease everybody and you will burn yourself out trying to do so.

Actually threatening you is different. That you need to escalate/ report.

NurseChester88 specializes in Medical Surgical.

4 minutes ago, MelEpiRN said:

1. follow up with provider/ follow pain escalation protocols if your facility has them. If that doesn't work?

Let. Them. Leave.

You will never appease everybody and you will burn yourself out trying to do so.

Actually threatening you is different. That you need to escalate/ report.

Thank you so much for your advice!

I have not been personally threatened. You are absolutely right about letting them leave. But what do I say so I don't come off as ”disrespectful, insensitive, bad nurse”? 

When I give hand off report to the next nurse, he/she states ”let them leave”. But by letting them leave with a terrible infection or bad condition, wouldn't things get worst? Patient most likely return in a worst condition? 

Every time I followed up with the NP on call in the floor, he rarely prescribes narcotics and wants to stick to the plan set up by the doctors who worK days, other times, he adds a higher strength Tylenol and he is very conservative with opioids but I understand and am fully aware of the opioid crisis. 

Also, when I am doing a late night admission after spending 1-2 hours doing patient admission, physical, dressing wounds, hanging antibiotics, labs, then hearing them say they want to leave because they are not getting what they want or need, makes me upset after all the work I have done. 
 

Sometimes, I feel that some people have terrible expectations of pain control or they are constantly ringing for pain meds and it is the nurse who gets all the backlash. 

 

Rose_Queen specializes in OR, education.

1 hour ago, NurseChester88 said:

But by letting them leave with a terrible infection or bad condition, wouldn't things get worst? Patient most likely return in a worst condition? 

Yep. But the patients have not only rights, but responsibilities. If they choose to leave, they have to live with the consequences. If they are competent to make the decision, it’s theirs to make. 

You hand the situation over to their physician first and let them deal with it.

NurseChester88 specializes in Medical Surgical.

15 minutes ago, Rose_Queen said:

Yep. But the patients have not only rights, but responsibilities. If they choose to leave, they have to live with the consequences. If they are competent to make the decision, it’s theirs to make. 

You are absolutely right! I just don’t know how to approach them... 

NurseChester88 specializes in Medical Surgical.

2 minutes ago, sevensonnets said:

You hand the situation over to their physician first and let them deal with it.

We don’t have a physician in the floor after 5 PM. The NP or MD covering the patient for the night do not come to see patients unless their patient is involved in a MET team (medical emergency team). Or unless is Very necessary (emergency). Most patients are seen by the admission hospitality at the ED. When patients get to the floor, the ED orders get transferred and we notifying them that the patient arrived to the floor but they rarely come to see them because they have already been seen at the ED by the ED doctor and admission hospitalist. Passing the buck doesn’t help at all. 

Contacting a patient's physician is not "passing the buck." You contact the physician first. 

NurseChester88 specializes in Medical Surgical.

19 minutes ago, sevensonnets said:

Contacting a patient's physician is not "passing the buck." You contact the physician first. 

Yes, I am sorry if I misunderstood what you said in your previous post. I always mention this to patients. This is what I have available for pain for you, I will contact your physician. But most times, providers are very set in their ways and don’t prescribe narcotics. Sometimes, it takes a day for providers to review patients’s chart, assessment, and pain to do something about it. 
 

I have also had providers tell me up front Prior to them leaving the floor shortly after I arrive on my shift: “he/she is seeking and this patient is very manipulative, she is only getting this... So try to be assertive”. Most plan of care decisions and medication changes happened during day shift at rounds, not on evenings or overnight. Sometimes, after begging to long, they might prescribed a One time order of Morphine 0.5 mL.  

Asystole RN specializes in Vascular Access, Infusion Therapy.

I've always given the patient the benefit of a doubt if they request something specific. If I don't have it as an option I asked their provider if it could be. 

Having been on the other side of things I can tell you that I personally have preferences for certain things and circumstances and sitting in pain sucks and can be akin to being tortured. 

I have found that it is easier and better to accommodate reasonable requests and then pull back as needed. If they are being unreasonable then they are being unreasonable, show them the door.

by TXRN

TXRN specializes in Perioperative, peds ,floor nurse,scl nurse.

As an RN & a chronic pain pt, I want pain relief yesterday. I have used all other treatment modalities. Give me my meds. I want quality of life.

TriciaJ specializes in Psych, Corrections, Med-Surg, Ambulatory.

1.  Express sympathy for the patient and intent to alleviate the pain.  "I'm sorry you're in so much pain.  Let's see what we have ordered for you."

2.  When that does not make them happy, state the situation and offer to call the doctor.  "I don't have that particular medication (or route) available.  Let me call the doctor to see what else we can do."  When you call the doctor, describe the pain-related behaviours:  writhing, grimacing (or laughing on the phone with someone, munching on a sandwich).

3.  If the doctor orders the requested med, great.  If not:  "I'm sorry.  I asked for what you wanted but he was not willing to prescribe it.  Let me give you what we do have, and let's see what other things we can do to get you more comfortable."

4.  If the patient refuses all other measures and demands to leave "The doctor would prefer you to stay, but if you need to leave, I understand.  I have an AMA form for you to sign."

5.  If the patient refuses to sign the AMA form, write on the signature line:  Patient refused to sign.  Typically, patients leaving AMA are not given prescriptions.

6.  If the patient doesn't leave, then he is still an inpatient.  Meet all requests for the desired drug by repeating "I've already given that information to the doctor and he is not going to order that drug.  What else can I do to help you get comfortable?"

7.  If you start having concern for anyone's physical safety, notify the charge nurse, the house supervisor and security.

8.  When speaking with this patient, make firm eye contact and speak in a low, slow, clear voice.  Try to maintain a sympathetic tone while delivering the bad news, but don't engage in arguing or justifying.

Hope this helps.  Good luck.

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