known addicted patients going out to smoke

[pugmom3]

I work on a busy MedSurg unit. Concerned about thorny issue of "allowing" patient going out to smoke who is a known drug addict (her own admission) with IV access. She is gone so frequently she misses her scheduled doses of vancomycin and invanz for a badly infected surgical incision, lab draws for vanc troughs, etc. Pt actually left and went home AMA and was gone over two hours, then wanted to come back because it was time for her next morphine shot.

Staff is split on how to handle this type of patient. Legal/ethical/liability concerns about her going off the floor to smoke, going home and returning with iv access still intact. Had UDS upon arriving back to hospital, was POS for marijuana. Need consistent plan of care that all staff will follow to reduce the manipulation, etc., that this patient does with staff.

How do you all handle this?

[elkpark]

I would consult with your risk management/legal department about how to handle these situations.

A growing number of hospitals are requiring that people who want to go out to smoke sign out AMA (if they're healthly enough to go outside by themselves, they are healthy enough to go home :)). Clearly, this person is not engaging in this behavior on her physician's advice ...

I used to work on the psych consultation-liaison team at a big, urban teaching hospital, and we were the people who got called in to deal with situations like this (in fact, I once had to deal with almost this exact same situation). In that situation, we got the staff and attending physician together, all went in to the room together and explained to her as a group that we were not the Holiday Inn, we were a medical treatment facility -- the physicians had recommended the treatment plan they considered appropriate and she was welcome to consent to or refuse the treatment. If she wanted to abide by the medical treatment plan (which would not include going outside and roaming around town), fine, and, if she didn't, she could be discharged AMA pronto. What she could not do was continue to live at the hospital while refusing to cooperate with treatment.

These are v. difficult situations. Best wishes!

[tewdles, RN]

I am a huge advocate of team meetings to sort out patient issues. Great advice elkpark.

[kids]

If she's well enough to be gone for 2 hours she doesn't belong in the hospital. Why has she not been transferred to homecare?

[pugmom3]

Thank you so much elkhorn and tewdles. The team meeting in the presence of the patient sounds like a very effective plan.

[pugmom3]

Hi Kids...

Good question! Actually she would not qualify for home care because (no surprise) she is not homebound!

Other option would be outpatient infusion center but that would require a picc line, also not a good option for a known iv drug abuser.

Best option would be to get her on po antibiotics and po pain meds and send her home. We'll see what happens.

[TwilightRNurse]

I work on a busy MedSurg unit. Concerned about thorny issue of "allowing" patient going out to smoke who is a known drug addict (her own admission) with IV access.

I would personally refuse to take her as a patient if she's going to be allowed to go off of the floor. Too much liability.

[pugmom3]

That is what has happened. There are at least 3 staff nurses on the day shift and 1 on the night shift now who will not take care of her anymore because of her behavior.

Our risk mgmt/DON/Legal folks are trying to see if they can refuse to admit her because of the liability.

[TwilightRNurse]

Add yourself to that list as well.

[pugmom3]

Absolutely! Have already done so.

[WickedRedRN, BSN, RN]

Did not see it mentioned, what does the MD have to say about this behavior? We have had to involve security with patients in the same situation. We called every time the pt disappeared, notified MD and documented the heck out of all her actions and antics. We had psych and chemical dependency involved as well, but eventually she signed out AMA when she realized that the MD stopped the IV pain meds, changed to po only and we removed the IV once we changed to po abx.

Good luck, its a difficult spot to be in. I hope you have a good team that can back you all up on this one.

[pugmom3]

Hey WickedRedRN,

Yeah, the situation with the MD is also sticky. The orthopod who admitted her initially called the floor to find out what had happened after she left ama and had called HIM to complain about how badly we had treated her. He wanted her to return to finish her iv abx. By that time she had been gone over 2 hours and the DON/risk manager said she would have to be readmitted thru ER or as a direct admit.

The orthopod called the hospitalist on duty and asked her to readmit the patient because it was going to take him 2 hrs to get there to readmit her himself. The hospitalist reluctantly agreed, but refused to order anything IV, ordered Bactrim po and percocet po and they didnt start an iv site on her. The orthopod was coming in later that night and it was left up to him whether or not to order IV meds. The patient was mad when she learned that they had not ordered IV morphine. She said, "Well I could have stayed at home to take pills."

It is certain to be adressed further because of the liability issues for the admitting doctor, the nurses, etc. When the patient realized that she was not getting anything IV, she immediately went outside and called the orthopod on her cell phone demanding that he order her the IV pain medicine. He just told her he would be in later to see her. He's had about enough of her also and would love to "fire" her as his patient.

Incidentally, we do have patients sign a waiver of liability form if they insist on going outside to smoke.