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!

Specializes in SCRN.

Educating a patient in such situation goes out the window. You can actually see that education is not reaching them. They want Dilaudid. If MD gives them 1 mg q 4, they will nag the nurse to ask to increase to 2 mg q4, then 2 mg q 2, etc. No amount of accommodation, education, compassion, common sense and non-pharmacologic intervention will ever be enough.

Specializes in SCRN.

One time I've had a patient use "Did you look at your hospital ratings online? They suck because you guys don't treat patients right. Well, guess what? I'm gonna make sure those ratings go down to zero. I will write a review every day, while in pain, and no one will ever want to come here, ever!"

OK. You do that.

Specializes in Medical Surgical.
On 7/7/2020 at 7:38 PM, TriciaJ said:

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.

Wonderful advice! Will follow through with this. Thank you so much!!

Specializes in Medical Surgical.
On 7/7/2020 at 7:46 PM, Sour Lemon said:

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.

Yes, I agree absolutely about a matter of fact approach, simple, direct, and easy.

It is a pain when physicians or providers don't reply or call back the floor within a reasonable time frame. The patient's behavior starts to escalate or they start to use their call bell every 5 minutes because no one is doing anything.

Specializes in Medical Surgical.
On 7/7/2020 at 11:38 PM, JKL33 said:

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).

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."

Thank you for your wonderful advice! I have had patients who demand to speak to a provider when they are experiencing severe pain. The times when I have approached a doctor because they were still on the floor. I have received the following comments from doctors: "Oh, she is seeking!", "she/he is trying to be manipulative", "I am not going to talk to this patient, I have already explained to this patient that I am not prescribing any more medicine to them", "I am not going to see the patient, they are getting dramatic and by coming to see them, I will be feeding the negative behavior (this was on a patient with an extensive history of opioids and IV drug use, who was screaming at the top of her lung for her nurse at the beginning of the shift *hint: me*, after explaining to her that they were not going to prescribe her anything and the 1 mg IV Morphine was not enough, she started to state that she was refusing her dinner, threw her dish on the floor and started to throw objects in the room. After 3 calls to the provider. The provider refused to come to talk to the patient because she wanted to follow the plan of care established by the doctors during the day.

Specializes in Medical Surgical.
12 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".

Thank you for your response. What do you mean by "do the ground work first"?

Specializes in Medical Surgical.
9 hours ago, Sour Lemon said:

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.

Yes, many of them want something to be done about it, they come out of their isolation room looking for the nurse and following the nurse around the hall, unit. Providers don't have to deal with this type of stuff.

Specializes in Medical Surgical.
2 hours ago, RN-to- BSN said:

One time I've had a patient use "Did you look at your hospital ratings online? They suck because you guys don't treat patients right. Well, guess what? I'm gonna make sure those ratings go down to zero. I will write a review every day, while in pain, and no one will ever want to come here, ever!"

OK. You do that.

Thank you for your response! OMG, I have also had a patient (actually, patients with history of IV drug use) state "This place sucks!", "They don't do anything for me", "I can take better care of my pain at home". Then, when I look at them, they say "You are doing the best you can sweetie, this is not towards you". Great!

Specializes in orthopedic/trauma, Informatics, diabetes.

As an orthopedic nurse, that is a very common problem. I just have to tell them that I have orders and that the PO goes before the IV. I will write on the white board what times they can have what.

If they want to leave AMA, that is their choice. I explain that I will not risk my license for anyone. We are lucky because, as a teaching hospital, there is always a provider available. Pushing it up it not passing the buck. We are not able to change orders.

I try to educate people that AMA means that if they have insurance, the stay does not get paid for. Every shift I have at least one pt that is a manipulator. You will get better at being firm about dealing with them.

Great thread! Thanks everyone for your contribution. OP I really hope you found some amazing ideas on here ?

10 hours ago, NurseChester88 said:

Yes, many of them want something to be done about it, they come out of their isolation room looking for the nurse and following the nurse around the hall, unit. Providers don't have to deal with this type of stuff.

I was a bedside nurse for 6 years before becoming a NP, RNs don't know half the stuff providers have to deal with on a daily basis behind the scenes.

22 hours ago, rzyzzy said:

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.. ?

20 hours ago, Sour Lemon said:

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.

This isn't my first rodeo. I was a nurse for years at every level of the hospital in a drug infested area before becoming a provider. I know exactly what RNs can and can not do unlike most MDs. I know when they are being lazy and trying to pass the buck. I also know when they have hit a wall with patient education, in those situations I can step in and fix things.

Problem is I get lazy pages all day long with nurses that didn't bother to intervene or investigate and simply didn't want to deal with the situation. Nurse do not understand even 20% what providers are doing on a daily basis with regards for patient care, so spare me the guilt that I am not at bedside of every problem patient 24/7.

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