How do u deal with Patients who "dig their own grave"

[Anagray, BSN]

How do u deal with patients who make their condition worse?

4 moths ago we had a patient ( cardiac floor) with slight problems. At 82 she did wonderful with a cath. She had no other major health problems, besides intestinal polyps, which were also taken care of.

I realise she was anxious and needy, but what she ended up doing was refusing to care for herself (she asked US to brush HER teeth), she made a problem out of every meal time, she didn't comply with physical therapist, so by the time her hospital stay was over, she was not able to walk even to the bathroom.

As a result, she was not allowed to go home and was taken to a nursing home.

Another woman, who i really liked, was heavy, with many problems - cardiac, diabetes, etc, was doing pretty good. Was released to go home. 3 months lated she came back and i just could not believe it was the same person.

She is now on MRSA isolation (bedsores), she is swallen and her hands shake pretty bad. Every time I see her husband he is coming back to her room with food: icecream, fried shrimp, candy, juice, sandwiches (on top of dinner), potato chips.

I can see that maybe they are older, depressed and just don't care, but is this really they way people want to die?

I had another woman who was almost 90. She blew through seceral cardiac procedures without complaining and abusing the staff, she made EVERY effort to start getting out of bed and excercising. She was so determined to get on with it, that she eventually got out to the rehab and moved on with her life, however much there is left.

All 3 of these women have no children, but what a difference in the way they approach their life and death.

What do u do with patients like that? Do u just try your best to make them comfortable, regadless of how distructive they are or do u make an effort to get on their case and try to get them to listen?

[Jenny P]

The first 2 women were telling you things by their behavior and I doubt if "getting on their case" would have helped them at all. The first lady may have needed a nurse to sit down and LISTEN to her; I wonder if she was fearful of activity now that she had cardiac problems. To be 82 and have no major medical problems, then have a heart cath; it makes me wonder what this meant to her and what SHE THOUGHT her future would involve.

And as for the second lady: it sounds like she and her husband did not understand what happened while she was hospitalized and how she could improve her life. Do you suppose he's bringing her food out of his love for her and lack of knowing what to do to help her? I think they needed a nurse to listen to them and then TEACH them about how to deal with her many health issues. It is so hard to meet some people's needs while they are hospitalized; my guess is that this lady should have been referred to a home health nurse and this wasn't done.

It is such a shame that these days we are so busy dealing with understaffing and high acuity and short hospital stays that we nurses are not able to meet these peoples' needs and help them care for themselves. I believe that our geriatric population that doesn't have family involved should always be referred to home health agencies and have some community support after hospitalization. That is my personal opinion, I happen to love geriatrics and hate to see them flounder after hospitalization.

[frankie]

Anagray,

There are a few things that take time for nurses to develop - like standing by and letting a patient struggle to put their shirt on - knowing that you could do it for them, but they need to do for themselves. So you restrain yourself from doing for the patient. The same thing happens emotionally or mentally with a patient. At a point you will see that it is not your decision, rather it is the patient's decision and wishes that the nurse must advocate and support. This may differ wildly with you personal opinion, but the patient has this right - as long as they fully understand the consequences.

I once had a patient in out patient cardiac rehab - 65 yr old with 3 MI hx and drank a bit and smoked a bit. He began having crescendo angina, and the cardiologist said "IF YOU DO NOT HAVE BYPASS SURGERY TOMORROW YOU WILL HAVE ANOTHER HEART ATTACK AND DIE - YOU ARE BEING FOOLISH" - I had a heart to heart talk with the guy, and he was so vain, he did not want a scar on his chest, leg, arm or anywhere else. I explained what would happen as he infarcted his heart away and became a cardiac cripple. He chose to refuse surgery. After his sixth MI, he died. His choice - not mine. But what I did do for this man was support his personal, informed choice. I did not scold him. He knew my personal opinion would have been for him to have had the surgery, but he did not want that.

hope this helps

frankie

[tattooednursie, LVN]

I have alot of patients in long term care like that. I just simply tell them something like : " Do you see all those residents who are so very ill they could not do anything if they tried to? Well I know you can, so enjoy being able to do things for yourself and enjoy feeling somewhat good while you still can." Sometimes I say that depending on the condition, but alot of times when they are whining about everything, its best to ignore them, or say something to change the subject.

[Youda]

Get yourself a copy of Lynda Juall Carpenito's "Handbook of Nursing Diagnosis." Excellent book. Every nurse should have one and give them at Christmas.

In it, Carpenito will give you some excellent interventions that sounds like they would help you, like for:

Impaired health maintenance

Ineffective therapeutic regimen

Nutrition imbalance

Noncompliance

Self-care deficit

Knowledge deficit

Relocation stress syndrome

Impaired skin integrity

social isolation, etc.

Well, you get the idea. Bunches and bunches of interventions that could help you identify the cause of the problem (it isn't going to be what you think), and how to make effective interventions. Hope that helps!

[canoehead, BSN, RN]

I think that once they are given information about their bodies and diseases then they have a choice to make. Some people choose to keep smoking, keep eating McDonald's, but it is their right, even though it is frustrating to us. For me, the problem came when I felt responsible for their choices, like refusing to deep breathe and cough, or ambulate. I think so long as you offer the chance to do everything they can to recover there is no reason to feel angry or guilty.

Except at those who have health care that we are paying for- but that is another debate. I try to keep it a separate issue in my mind. and also remember that I am not perfectly compliant with exercise/eating right either.

[hoolahan, ASN, RN]

".....it is the patient's decision and wishes that the nurse must advocate and support. This may differ wildly with you personal opinion, but the patient has this right - as long as they fully understand the consequences. "

Extremely well-said Frankie!! Esp, "as long as they understand the consequences."

Youda, what a breath of fresh air and inspiration to nursing you are!!! Even tho I hate the whole nursing diagnosis/care plan thing, that book is an excellent resource for what you can do, and listening as Jenny P pointed out too, is the best first step, b/c it usually isn't what you think the problem is. Maybe they go to the soup kitchen to eat and have to have hot dogs or fatty foods. I saw bkft at the soup kitchen one day, included donuts and coffee, what about all those homeless diabetics, they are hungry and will eat what they can get. Granted this is not always the case, but psychsocial issues must be considered, look for the barriers to compliance.

"For me, the problem came when I felt responsible for their choices..."

Another excellent insight! Once you have educated, listened to them, tried your best to implement ways to remove barriers to compliance (got a social worker who assitsed them with housing, or meals on wheels, or whatever), then sometimes, it's just that they are just different from you, and you cannot control them.

It is very easy to get burned out with these kind of pt's, which you will see alot in cardiac care. My first impulse to reply to your post "How do u deal with Patients who "dig their own grave"", was to say "Hand them a shovel", but after seeing the wonderful replies you got above, I thought I should hold back on my cynicism! LOL! But, iut is true. I remember one man who was in CHF, kept whining for something to drink w his fluid restriction. As nicely as I could, I explained over and over the risks he was taking if he took in too much water/fluids. He didn't care, so I filled up his water pitcher, put it on his bedside tabel, and said, "Here, knock yourself out! Call me if you feel short of breath!" And I walked out. I figured what was the worst that would happen? I'd have to give some extra lasix. When he leaves the hospital, he will do what he wants anyway, so why kill myself ? Educate them, and move on to the other pt who is willing to change.

I used to feel responsible, but since I started to do homecare, it has really opened my eyes to the barriers that are present, the attitudes, and "interesting" lifestyles I see, and am more often than not powerless to change. So, I do the best I can, and no longer feel responsible for the choices of others or their consequences.

[zudy]

Anagray, i know how frustrating non-compliant pts can be. If you were to look up " non- compliant pts" in the dictionary, my mom's picture would be there. She fires drs on a regular basis, wil wash down an extra glucophage with coke " to even things out" refuses to take lasix until sob or back into chf. My sister is also a nurse and you know what? We can't let it make us crazy. I give as much love and support that I can, encourage her. She is well educated (Masters in biology) smart, funny, but absolutely stubborn and will have things HER way. All I can do is offer options. If me telling her and all my pts what to do is all it took, we would all be perfect!

[BadBird, BSN, RN]

I will tell the patients the consequences and then let them make the choice, I do not walk in their shoes and I do not pass judgement. I used to feel frustrated but as I got older and gained more tolerance of others I just came to accept what I can not change. That said, if a patient is taking up a ICU bed and is non compliant then I feel that they should be discharged home, no since wasting good nursing care if they just don't want to help themselves.

[Audreyfay]

The only thing I might add, is sometimes having a psych social worker or therapist get involved MIGHT help. Sometimes the older folk aren't agreeable to this, but it's worth a try.

[Nurse Ratched, RN]

I see this every day. It's frustrating, but to use kid's logic, I am only the boss of me lol. When people know the consequences of their actions and still choose to do things that are unhealthy or contraindicated, as long as they are of sound mind to make their own choices, that's that.

However, I agree with Canoehead that when the bad lifestyle choices of others come out of my pocket, then I'm miffed. In fact, me thinks we DO have another thread coming on this very topic.... :)

[Weenurse]

There's a young lad who frequently comes to our hospital whois most definately "digging his own grave".He's a 20 yr old asthmatic, comes into A&E at least once a week, is admitted to our ward at least 2-3 times a month and has had 3 itu admissions since his early teens. The problem is that he always self discharges. On the ward as soon as his aminophyline infusion is discontiued he leaves, the last time he didn't even wait for the infusion to finish. He disapeared and the pump complete with infusion was found dumped in the hospital grounds!! Drs have spoke to him many times, warning him he will kill himself if he carries on this way, one Dr has refused to treat him but of course two days later he's back in again 'cos he's not been using his inhalers! I have suggested that he is charged for his treatment ( health care in UK is free) but nothing changes.One of these days he'll be a BID!! makes me mad!!!!