How would you handle this ....

[RUBICON, RN, EMT-P]

It always amazes me the stories & experience we get each day. Here's another. How would you handle it?...

A gentleman has been in the ICU for *only* a week after suffering a cardiac arrest at home, in which he was resuscitated by EMS and had no neuro sequalae as determined by an MRI. Skipping to the chase, he is developing ICU delirium (in my opinion), becoming more agitated with his stay and noticeably irritated whenever family arrives. He is sassy and mean to his wife, and he is mocking the care he has received. He eventually pulls out his PICC line, demands to leave AMA, and says the doctor is allowing him to go outside for 2-puffs of a cigar. He now gets a Sitter. He does have psychiatric disorders, and a psychiatric consult is ordered, of which he refuses the evaluation. After getting downgraded from the ICU to his new room, he refuses it, complaining of small details.

After a short stalemate, the supervisor brings him back into the ICU room, where he was demanding to go back. Now the fun begins: the ICU doctor says the man was downgraded, and there was no medical reason to bring him back in and that it was wrong to do this. The patient is not under ICU service any more and he is someone else's problem .. the Hospitalist. The Hospitalist doctor arrives and says he cannot offer the man anything we have not already done. The 2 doctors discuss options and both state that the man has no choice and can be physically removed by Security and restrained if need be.

Now, I may not know much, but I'm pretty certain if that route were taken, you would be learning about this on CNN and not thru Allnurses.com; eventually the Supervisor finds an "acceptable" option of another room, and the patient even mocks this, but is willing to go while continuing to say he has called a Taxi and he knows what we cannot do: detain him. The ICU doctor states the man is not under psychiatric certification, but that he is medically delirious and cannot be allowed to leave because he lacks capacity, and that he will continue to attempt to manipulate us into believing he is okay.

Now, again, I may not know much, but after caring for the patient for 4 days and watching him progress, etc, I'm pretty certain the patient was not mentally incompetent and, although I do not impress upon AMA, in this particular instance ... let him .. we've done what we can in a week, he's stronger, and maybe all this poor behavior/ attitude/ decisions is simply HIM.

How would you handle it?

[K+MgSO4, BSN]

Formal cognitive assessment to see if he is in a delirium. If he is then he is not competent to leave. Sitter and delirium protocol.

Probably too late in the episode but he could of been withdrawing from alcohol or other substances.

Otherwise he is just an ***. You can't fix stupid, let him go.

[RNperdiem, RN]

My first thought is withdrawal too. He really needs that psych evaluation for the doctors to make an informed decision about what to do next. Sometimes a patient can stay in ICU for nursing needs.

[CharleeFoxtrot, BSN, RN]

8 hours ago, K+MgSO4 said:

Formal cognitive assessment to see if he is in a delirium. If he is then he is not competent to leave. Sitter and delirium protocol.

Probably too late in the episode but he could of been withdrawing from alcohol or other substances.

Otherwise he is just an ***. You can't fix stupid, let him go.

I was thinking withdrawal as well. Sometimes we forget that sweet little ol lady or proper elder gentleman could be addicted to various substances and when they begin to detox...yikes.

[Jory, MSN, APRN, CNM]

If I were the physician I would write discharge orders and send him out the door. If he is well enough to leave the unit (which is STUPID post MI), he is well enough to go home.

He is refusing care. If he isn't mental enough for a psych TDO (from what you have described, he will not meet legal criteria), then you can send him home. Offer him inpatient rehab or skilled and if he turns it down, document it, discharge.

Patient is not getting ICU delirium, he is manipulative. Hospital is getting very close to where they aren't going to get paid for his stay and moving him back to the ICU "because the patient requested it" is insurance fraud if it is billed at ICU rates when he didn't meet criteria.

If he's been in the hospital for over 10 days, any withdrawal is doubtful. It would have manifested itself long before this. Most patients fall under a "three day rule". You'll see most withdrawal after three days or a little after. To start at 10 days would be very, very rare.

[LibraSunCNM, BSN, MSN, CNM]

I think the key problem is that he never had a formal psych consult---he "refused" it. In my opinion, if a medical provider thinks a patient needs a psych consult, they can't then actually refuse---the psych provider has to do the best they can to evaluate the patient. Who knows if he was in withdrawal, delirious, or just manipulative and mean---no one got to the bottom of it.

[RUBICON, RN, EMT-P]

I refrained from saying the psychiatric background, because too often times we jump on the "he's Bipolar" or "he's a Schizo" train as if it's the definitive answer for his immature & annoying behavior. And it certainly factors in, especially his ability to manipulate where he got to go each time. I couldn't see manhandling him into a room and "restraining him if need be" for the sake of his not accepting anything less of his ICU bed and care. I felt that was ridiculous on the doctor's parts to suggest this.

I guess the focus on this Post asking how you would handle it, is that it became a matter of someone else's problem, from the doctor to the nurse, and on somehow making him accept his new environment. "If he refuses, then Security has to do something about it" as the Hospitalist said. What? You cannot force this man into doing or accepting what he doesn't want. You also cannot allow him to manipulate and drive the bus, as he was doing. And the nurse is always caught in the middle.

[RUBICON, RN, EMT-P]

Jory, I'm so in agreement with you. Manipulative. We wouldn't allow this man to leave because he supposedly lacks capacity while he's up walking around ad-lib, voluntarily deciding what he can & will not do, expressing his rights, this is America, etc. ... yet only 3-4 weeks ago, another patient was brought back from the brink of death following an intense course of treatment. We literally saved his life. He also mocked us and his care, this is America, etc all the while arguing very well that he was okay to go home. In the end, we gave him extra clothing and he walked out AMA to his awaiting Taxi cab. That ICU doctor said the patient can make stupid decisions, this is how the world rolls.

[AlwaysLearning247, BSN]

Unless they’re sectioned, let em go. We can’t fix certain people who don’t want our help. I have been in situations where a patient has been out of control and confused, trying to leave. I call the doc and they section them and get psych on board. It gets sticky dealing with this stuff legally sometimes!

[Jory, MSN, APRN, CNM]

On 9/21/2019 at 9:30 AM, RUBICON said:

Jory, I'm so in agreement with you. Manipulative. We wouldn't allow this man to leave because he supposedly lacks capacity while he's up walking around ad-lib, voluntarily deciding what he can & will not do, expressing his rights, this is America, etc. ... yet only 3-4 weeks ago, another patient was brought back from the brink of death following an intense course of treatment. We literally saved his life. He also mocked us and his care, this is America, etc all the while arguing very well that he was okay to go home. In the end, we gave him extra clothing and he walked out AMA to his awaiting Taxi cab. That ICU doctor said the patient can make stupid decisions, this is how the world rolls.

But unfortunately, the way our healthcare system is set up, you can't fix everyone. I have a close colleague who is an FNP hospitalist, so I hear quite a bit of what goes on in the rest of the hospital. Elderly woman went home, they called APS, she could not walk, could not get up on her own, had minimal help, yet insisted on going home by herself.

She is legally allowed to put herself into an unsafe situation. She didn't have dementia, but she wasn't sick enough to be in the hospital. Anytime she needed anything, she would call 911, it was ridiculous. It took several of these trips before enough evidence was gathered to take the case before a judge to have her declared legally incompetent. Then her choices are taken away.

Even if patients are sent to a nursing home, if grandma doesn't want to take her anticoagulants, is oriented, can make her own decisions, and she has a stroke and dies? She's allowed to do that.

[Snatchedwig, BSN, CNA, LPN, RN]

Document document document. Option A. Assessment and documentation demonstrate the patient is not of sound cognition, then restrain him. Option B. After assessment it shows he cognitively sound, give him the AMA papers and say deuces.

It sounds like he is option B.

[JKL33]

On 9/20/2019 at 10:58 PM, RUBICON said:

The ICU doctor states the man is not under psychiatric certification, but that he is medically delirious and cannot be allowed to leave because he lacks capacity, and that he will continue to attempt to manipulate us into believing he is okay.

Well, what you (the team) can't do is state/believe that, and then not follow through. If that is the physician's assessment, then everyone has a duty to respond accordingly - which clearly does not involve allowing someone to sign out AMA while stating they lack the capacity to make the decision to do so. You can't even technically sign out against advice if the assessment is that you lack the capacity to weigh the advice.

What was "probably" going on with the guy is irrelevant. The physician who has been responsible for his care up to this moment has assessed the patient as lacking the capacity to make an informed decision about leaving. So either he is allowed to elope while the physician states that he lacks the capacity to decide to leave, or he is held there and kept safe while a more formal means of keeping him there is pursued.

The facility is not on solid ground allowing the individual to elope under those circumstances. And it would be called elopement, not signing out AMA.