How to handle patient’s threats

Nurses General Nursing

Updated:   Published

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!

Don't bang your head into a wall suggesting Tylenol or heating pads for a patient "demanding" IV Dilaudid. Call the doctor, then get the order or get the refusal.

If the patient doesn't get what they want and they leave, that's that. There's nothing you can say to them that they haven't heard 100 times before. Believe it.

If you act personally affected by their threats to leave, they're going to get 100 times more dramatic before they finally make an exit. A flat, matter of fact approach is best.

I agree that you must inform the responsible provider if your patient reports that their pain is not controlled with the interventions ordered/already tried.

Be prepared with a brief description of the pain, set of vital signs, patient's words/requests, other pertinent observations. When you call, state your very brief case synopsis (Mr. X in room 1234 admitted with xyz diagnosis) and the brief report of patient's pain situation despite interventions. Make your request (or the patient's request).

If the provider doesn't wish to change the orders, return to the patient and state, "I have contacted Dr. So-and-so about your pain, and s/he wants to continue your current plan of care for now. If you would like, we can come up with a specific plan for how to keep you as comfortable as possible this evening" (scheduling meds combined with other interventions, etc.). State, "I would really like to help you be able to rest more comfortably."

If the patient is disgruntled/verbally aggressive, stay calm, speak in quiet low tones and reassure them that you will help them as best you can within your professional abilities. If they threaten to leave, calmly and kindly state, "I would hate to see you leave because it's important that you receive treatment for [xyz, your infection, etc.], but we cannot force you to stay here."

Remember that you are on the patient's side, while at the same time you are not responsible for "making" a provider change the plan. That is between them and the patient.

If you need help beyond this, contact your charge or supervisor and state that the patient is not happy with their plan of care and you need some assistance. The provider also needs to know if they patient is threatening to leave AMA (even if you have to make a second call at some point to tell them).

12 hours ago, NurseChester88 said:

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.

I know it is difficult, but you have to keep your emotions out of it other than to perform your professional duties appropriately. That is your job. Your job is not to make everyone be happy come what may. Try to begin being more mindful of when you are feeling personally hurt by these things. When you recognize feeling hurt, double-down on the professionalism, calmness and commitment to helping the patient as best you can within your means. Then you will know you have done everything you can do, and you *must* let the rest of it go.

Oh, lastly: If the situation warrants, don't be afraid to state (to the provider) "I am requesting someone come and look at the patient."

20 hours ago, Asystole RN said:

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.

As a patient I can tell you I appreciate when someone will listen to me on such things if you give me that antibiotic in pill form, I will be puking everywhere please give it to me via iv. No I don't want that xyz pain medication because I will turn into a very angry patient that will need even more medication for you to deal with me. Please don't give me opiates start with minimal medication first. Please don't give me anxiety medication because my body reacts oddly to it. I know my own metabolism and I know what my body will do with certain medications.

Once you have made the patient as comfortable as you can with what has been ordered, it is not your fault and needs to be passed on to someone who can deal with it and knows the patient history. If it out of your scope of practice there is nothing you can do other than to call for help and keep advocating for the patient. Please do not tell a patient that you will call their doctor and then not do it. Once a patient finds out you have not followed through they will lose all trust in you. If they are threatening to leave AMA because you won't up their pain medication, then get someone else needs to come in and talk to them about their options. The same as when a patient refuses a medication or some type of care you cannot take that personally either. It is their body and their choice. Once you have explained what is the possible result and the patient understands then all you can do is keep giving patient care and hope for the best. As far as a patient leaving AMA, they have a right to leave and go somewhere else for a second opinion, even when you feel it is not in their best interest. Once you have explained all that and you are sure they understand, then again it is their body, their choice.

But if you are ever physically threatened then get someone there as soon as possible.

Specializes in SICU, trauma, neuro.
On 7/7/2020 at 6:01 PM, TXRN said:

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.

Exactly... I don’t know this pt’s story but unless this is a new and minor thing (say, rolled his ankle when he got up to ambulated) I would offer the non-pharm things as an adjunct — not as an alternative. Especially if the pain is unrelieved after several shifts of PO pain meds... if that’s the case, is ice and elevation alone REALLY going to be effective? Unlikely.

Sometimes people really do just know what works for them... I’d rather give a “seeker” the benefit of the doubt than torture someone who truly needs pain relief.

It’s not passing the buck to involve the provider — you don’t have prescriptive authority.

If the pt wants to leave AMA that’s his right. As long as he’s made aware of the risks he’s running by leaving, he has that right.

A few years ago a patient left AMA just after receiving tPA; she was given it at an outside facility and transferred to us. When she found out that no the ICU can’t accommodate her smoke breaks she flatly refused... this was after talking to both the resident and attending neurologist, and the nursing supervisor. She made a potentially really bad choice and I hope she did OK after leaving, but competent people have autonomy and are free to make bad decisions.

As far as being respectful, I keep my tone and words neutral and not judgmental. Let him know that per policy here’s the form I have to go over with them, risks of leaving and things to watch out for/please seek attention for.

So say it’s an infection he’s needing IV antibiotics for.... sorry I don’t remember this pt’s story (read your post a couple days ago) but infection is ringing bells. There’s a difference in respect if you say “this is a bad decision and your infection is just going to get worse” and “the risk of leaving now is this infection won’t be adequately treated; you should call your PCP for a/b/c sx — or go to the ED for x/y/z sx. Do you have any questions about that?”

Again just neutral, factual wording and tone.

On 7/7/2020 at 10:07 AM, NurseChester88 said:

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!

“I’ll notify the doc of your concerns and get back with you “.

Done.

you can’t give what isn’t ordered and your algorithm / protocol obviously doesn’t allow what they’re asking for.

no reason to tie yourself into knots over something that’s outside your control.

Specializes in ER.

RE pain meds "It's not my decision, but I passed on what you said to the doctor." Repeat. Repeat.

Keep coming up with simple comfort measures so they know you are on their side, but "I told the physician, they know." is always on repeat. You only have to notify the doc once, unless you think he's really forgotten about them.

If they threaten to complain or sue, "That's your right," and continue with your care. Don't ever reward them when they do this, suddenly being more attentive will make things worse.

Make sure you check on them at least hourly and chart it.

Some of our chronic pain patients respond well to Haldol or buscopan, depending on the situation.

Specializes in SCRN.
On 7/7/2020 at 9:50 AM, NurseChester88 said:

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?

True, but that is not your problem. THEY choose to leave and retain a little control for themselves. You cannot fix the grown human's problems if the human does not want them fixed.

Specializes in Retired.

We used to call this the AAYOYO discharge. Adios, A-hole. You're on your own. Manipulative patients are difficult. I just told myself over and over "It's just temporary" to help.

On 7/7/2020 at 9:34 AM, sevensonnets said:

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

This is such a piss poor response. You can definitely educate patient before escalating. Seriously, use your nursing skills and judgement to de-escalate before calling the provider. I am so sick of nurses just using CYA tactics because they don't want to do their job. Educating and explaining protocols is definitely within a RNs scope.

I have 15+ patients, you have 3-5 in most situations. Do some of the ground work first, otherwise this makes nurses look like no more than glorified med-passers. I swear I get so many empty/hollow pages where the nurse literally did nothing to investigate a patient's complaint just so they can put in their RN note, "provider notified".

On 7/7/2020 at 4:01 PM, TXRN said:

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.

Yeah that's not how it works.

1 hour ago, Numenor said:

This is such a piss poor response. You can definitely educate patient before escalating. Seriously, use your nursing skills and judgement to de-escalate before calling the provider. I am so sick of nurses just using CYA tactics because they don't want to do their job. Educating and explaining protocols is definitely within a RNs scope.

I have 15+ patients, you have 3-5 in most situations. Do some of the ground work first, otherwise this makes nurses look like no more than glorified med-passers. I swear I get so many empty/hollow pages where the nurse literally did nothing to investigate a patient's complaint just so they can put in their RN note, "provider notified".

A patient demanding an opiate via IV vs p.o. isn’t going to “de escalate” to Motrin and a hot pad.

Patients at that level know the drugs and the “protocols” better than the nurse does.

a yell fight over something the nurse literally has no choice about doesn’t help anyone.

I've frequently got 20 patients in my current environment & have had 35 in some places.. not 3-5.. ?

2 hours ago, Numenor said:

This is such a piss poor response. You can definitely educate patient before escalating. Seriously, use your nursing skills and judgement to de-escalate before calling the provider. I am so sick of nurses just using CYA tactics because they don't want to do their job. Educating and explaining protocols is definitely within a RNs scope.

I have 15+ patients, you have 3-5 in most situations. Do some of the ground work first, otherwise this makes nurses look like no more than glorified med-passers. I swear I get so many empty/hollow pages where the nurse literally did nothing to investigate a patient's complaint just so they can put in their RN note, "provider notified".

I don't know what population you work with, but most of the "specific-drug demanding" patients I work with are very well-known to their providers. And it doesn't matter if you have two patients on the floor, or if you have sixty ...because you won't see any of them.

You will spend all of your time with that one patient until they get a firm, straight-forward "yes" or "no" answer. They are relentless and unconcerned with any other person's needs. We can't ignore their constant calls to take care of our other patients, and if we did, they'd come wandering through the halls and find us.

Contacting the provider is the only way to get that answer for them so they can settle in or head to the next ER.

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