How to let go

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Specializes in allergy and asthma, urgent care.

Hi everyone,

I'm a new NP working in the urgent care department of an urban community health center. I have been following one patient with COPD and pneumonia for the last few weeks as her PCP is booked solid for months. She's not improving on oral antibiotics (non-compliance and smoking are issues), and when I saw her yesterday I wanted to admit her as she's not doing well. She has a history of breast cancer and I'm a little concerned about a recurrence or mets, given that she's not getting better. She refused to go to the hospital, refused to have labs drawn or imaging done. I had her sign a document that she understood she was acting against medical advice. I know intellectually that this is her choice and her right to refuse treatment, but I keep thinking I should have done a better job convincing her to do something. I spent most of the night lying awake thinking about this. I'm hoping this is just new NP worry, and with time I'll be able to detach a little more. I'm going to burn out pretty quickly if I let all my non-compliant patients get to me like this. I'd welcome any advice/thoughts on how to let go of the worry.

Thanks.

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Specializes in Family Practice, Primary Care.

It is her life, so she has the choice to do whatever she wants.

That being said, it is NOT your fault and you did your best.

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Specializes in Nephrology, Cardiology, ER, ICU.

My advice: ensure you are documenting very well. I work in nephrology and have many noncompliant pts. I document each and every conversation including paperwork that they sign in my notes. An additional step that I take is to document a discussion/conversation with the pts attending MD. I make a note everytime I discuss this pt. I document phone calls to patients, appts made for referrals, absolutely everything.

In the end, yes, it is their choice to choose or not to choose to take good advice. However, in reality, we can all be sued, so it is better to be safe than sorry.

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Dont forget to write in your notes that you explained what will happen to her by refusing to comply with tx. That you explained what smoking does and offerd help for smoking cessation, you discussed the new meds, tx, all that stuff.

Wasn't there a case recently where providers were sued for not documenting that smoking was bad and a cause of lung cancer (common knowledge) but yet got sued and lost the suit because the pt got lung ca and died. "well you never said it was bad for me and that I should stop."

As for the emotional aspect, I know it can be so frustrating to watch them dig their own grave. However, I have decided to take the approach that I've done my job by stressing to them what their choices will cause. If the pt still does not want to do anything about it I tell myself that I must respect thier decision and let it go, it's not your life, not your choice, you can't fix everyone...

I know some practices sever their ties with pts like that because of the liability involved. A COPD/emphysema pt will eventually develop respiratory failure and die.

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Specializes in allergy and asthma, urgent care.

Thanks to all who replied. Yes, I took extremely detailed notes and documented every aspect of our discussions, including the several follow up phone calls I made.

I was able to discuss my feelings about this with several co-workers, and I have to accept that patients have the right to choose to have treatment or not. I think that will be easier as I gain experience, but I hope that it never completely stops bothering me. I don't ever want to be that jaded or detached.

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Check into the liability with continuing to see a patient who is non-compliant. Others have gotten into trouble for continuing to see non-compliant patients who ran into trouble even with excellent documentation.

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Specializes in Nephrology, Cardiology, ER, ICU.

That is true if you are a primary care practice that can get another practice to take on your noncompliant pt. Doesn't work if you are the only game in town as a specialist practice.

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Thanks for clarifying!:D

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Specializes in allergy and asthma, urgent care.

I work in a federally funded community health center and we can only "fire" our patients if they violate laws (i.e. diverting narcotics or bringing in a weapon) or if they threaten staff or other patients. Most of these people have nowhere else to go, and unfortunately, many are non-compliant. We just have to document as precisely as possible and get those AMA forms signed.

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Specializes in Nephrology, Cardiology, ER, ICU.

Yes indeed.

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