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.
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.
I am curious how you are so confident in that. A PT with a psych history spends 10 days in ICU, deprived of REM sleep, subject to incessant nuisance alarms, have a variety of psychoactive meds running through his body, poked and prodded at random times..... If that was done to a POW, there would be a war crimes tribunal. It doesn't seem that far fetched that this could lead to an exacerbation of psych symptoms. Also, being dead, even for a little while as he was, could take a bit of a toll.
I am not naive about manipulative patients. Most of the my last 15 years has been spent in an ER in a hospital with both psych and rehab services. I understand manipulative behavior, and I understand that often the underlying problem is ideopathic shmuckosis, a syndrome with no effective treatment.
But in this case, it is worth looking at all the possibilities.
But then I remember that I cannot care more about my patient than s/he does about him/herself.
Ah, but you can, and you must if the standing assessment is that the patient doesn't have the capacity to understand the situation. In such a situation, the reason that the patient doesn't [appear to] "care about" him/herself is because s/he can't.
The presence of delirium does not automatically mean the patient lacks capacity to decline treatment, including leaving AMA. In order to have the capacity to chose to leave AMA, the patient only needs to be able to show they understand why further medical treatment is being advised and what we believe the risks are to declining further treatment, they don't necessarily need to agree with our reasoning, just comprehend the reasoning.
As for refusing to accept a new room, I've had a number of patients over the years where this is the case, and typically the worst thing you can do is fail to maintain that most basic of boundaries and limits. Typically patients give up once they realize this particularly testing of the boundaries has failed, but I have seen it come to forcibly removing patients from a room they are no longer allowed in.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
OP, I am confused because you state that you think the man is experiencing ICU delirium but then you also state that you think he is mentally competent. Which do you believe? Because these are mutually exclusive.
I agree with the PP who stated that the psych consult cannot be refused. The patient can refuse to answer questions, refuse to speak, etc. But the psych assessment is still going to happen. It's not optional for someone who may be experiencing a psychiatric crisis.
I can't tell if you have a manipulative guy at his baseline or a person experiencing delirium or a person with chronic mental illness who is decompensating. Any of these is possible. A crisis screening or psych consult would determine that. It should not have been "refused".
While I can respect your attempt to decrease stigmatizing labels by leaving out the info about his chronic mental illness, this info is extremely important. If you've got a bipolar patient who has been off his mood stabilizer for a week and showing signs of mania, well that needs to be addressed. Or maybe he hasn't been off his lithium, but the diet and other drugs hes been on while hospitalized have messed up his levels. The psych history is important.
OP, I am confused because you state that you think the man is experiencing ICU delirium but then you also state that you think he is mentally competent. Which do you believe? Because these are mutually exclusive.
I agree with the PP who stated that the psych consult cannot be refused. The patient can refuse to answer questions, refuse to speak, etc. But the psych assessment is still going to happen. It's not optional for someone who may be experiencing a psychiatric crisis.
I can't tell if you have a manipulative guy at his baseline or a person experiencing delirium or a person with chronic mental illness who is decompensating. Any of these is possible. A crisis screening or psych consult would determine that. It should not have been "refused".
While I can respect your attempt to decrease stigmatizing labels by leaving out the info about his chronic mental illness, this info is extremely important. If you've got a bipolar patient who has been off his mood stabilizer for a week and showing signs of mania, well that needs to be addressed. Or maybe he hasn't been off his lithium, but the diet and other drugs hes been on while hospitalized have messed up his levels. The psych history is important.
A patient can be experiencing some level of ICU delirium and still have decision making capacity, or 'mentally competent'. There is certainly a subgroup of patients experiencing ICU delirium who also lack capacity, but no, there are not mutually exclusive.
A patient can be experiencing some level of ICU delirium and still have decision making capacity, or 'mentally competent'. There is certainly a subgroup of patients experiencing ICU delirium who also lack capacity, but no, there are not mutually exclusive.
That's my take as well, lots of grey areas in this scenario so no blk/white.
A patient can be experiencing some level of ICU delirium and still have decision making capacity, or 'mentally competent'. There is certainly a subgroup of patients experiencing ICU delirium who also lack capacity, but no, there are not mutually exclusive.
Part of the problem in the OP scenario is questionable use of terminology and/or use of terminology that means something specific without undertaking proper assessment to better define the situation. People (even HCPs) have a hard time using words like incompetent, delirious, incapacitated, not competent, lacks capacity, etc., properly in a medical context and instead use them almost like lay terms. For example, it's not that uncommon to hear someone say something like, "He's not competent to leave - he's intoxicated!" There is an inappropriate application of terminology combined with wrong conclusions. Sometimes the misuse of terms contributesto the wrong conclusions. Then others insist that patients are allowed to make bad choices - - which may be true but certainly isn't always true.
Anyway, in the OP case, it does kind of sound like even the physician is kind of throwing the terms out there. But then it would be within a nurse's role to clarify what the physician means by his/her statements. Is the patient experiencing some degree of delirium but demonstrates that he does have the capacity to make the decision to leave, or is he experiencing some delirium and it is affecting is capacity to make a decision to leave, or is he not delirious and is just belligerent...or some other situation.
Whatever the assessment reveals, though, we then should follow through. If the patient is properly assessed and found to lack the capacity for a decision to leave, then it's not okay for half the crowd to pipe in about how "patients have the right to make bad choices" and allow him to leave "AMA."
Specializes in Psychiatry, Community, Nurse Manager, hospice.
7 hours ago, MunoRN said:
A patient can be experiencing some level of ICU delirium and still have decision making capacity, or 'mentally competent'. There is certainly a subgroup of patients experiencing ICU delirium who also lack capacity, but no, there are not mutually exclusive.
I know that, my point is not about whether or not a delirious patient can make certain medical decisions.
My point is that I am confused about what the OP thought about the situation. It seems like s/he thought the patient was delirious and then also implied that this is just the way the patient is.
And by the very definition of delirium, those two things can't be true.
I only used the term mental competence because OP did. Competence is a whole other animal.
I still really do not understand what the OP thought should have happened here.
I know that, my point is not about whether or not a delirious patient can make certain medical decisions.
My point is that I am confused about what the OP thought about the situation. It seems like s/he thought the patient was delirious and then also implied that this is just the way the patient is.
And by the very definition of delirium, those two things can't be true.
I only used the term mental competence because OP did. Competence is a whole other animal.
I still really do not understand what the OP thought should have happened here.
11 hours ago, JKL33 said:
Part of the problem in the OP scenario is questionable use of terminology and/or use of terminology that means something specific without undertaking proper assessment to better define the situation. People (even HCPs) have a hard time using words like incompetent, delirious, incapacitated, not competent, lacks capacity, etc., properly in a medical context and instead use them almost like lay terms. For example, it's not that uncommon to hear someone say something like, "He's not competent to leave - he's intoxicated!" There is an inappropriate application of terminology combined with wrong conclusions. Sometimes the misuse of terms contributesto the wrong conclusions. Then others insist that patients are allowed to make bad choices - - which may be true but certainly isn't always true.
Anyway, in the OP case, it does kind of sound like even the physician is kind of throwing the terms out there. But then it would be within a nurse's role to clarify what the physician means by his/her statements. Is the patient experiencing some degree of delirium but demonstrates that he does have the capacity to make the decision to leave, or is he experiencing some delirium and it is affecting is capacity to make a decision to leave, or is he not delirious and is just belligerent...or some other situation.
Whatever the assessment reveals, though, we then should follow through. If the patient is properly assessed and found to lack the capacity for a decision to leave, then it's not okay for half the crowd to pipe in about how "patients have the right to make bad choices" and allow him to leave "AMA."
I agree with both of you on the terminology issue, I was only references the two terms to avoid the wrath of the terminology police. The details and context of the situation as described negate the need to get picky about which terms we use.
Mainly I was referring to the common misperception by others that if someone is in any way 'off' cognitively that they can't then choose to leave AMA.
Specializes in orthopedic/trauma, Informatics, diabetes.
Sounds like some situations that happen where I am at. We work very hard to get people treated. We don't "dump" pts (not saying that your facility did). We get to keep them until most issues are resolved. In 7 years, we have had one repeat patient that was finally discharged from the ortho service and could not come back to our floor. This pt could still come to hosp, but not us.
Sounds like this guy had some psych issues that needed to be dealt with.
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I am curious how you are so confident in that. A PT with a psych history spends 10 days in ICU, deprived of REM sleep, subject to incessant nuisance alarms, have a variety of psychoactive meds running through his body, poked and prodded at random times..... If that was done to a POW, there would be a war crimes tribunal. It doesn't seem that far fetched that this could lead to an exacerbation of psych symptoms. Also, being dead, even for a little while as he was, could take a bit of a toll.
I am not naive about manipulative patients. Most of the my last 15 years has been spent in an ER in a hospital with both psych and rehab services. I understand manipulative behavior, and I understand that often the underlying problem is ideopathic shmuckosis, a syndrome with no effective treatment.
But in this case, it is worth looking at all the possibilities.