Need serious help dealing w/manipulative patients

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I don't feel like going into detail about the patient and family member right now, but I know I need some helpful advice on how in the world to handle these two insanely manipulative people.

This pt is very sick and whilst he/she and the family member are seriously impeding his/her chances of getting better, which shoud easily be happening, instead, they are speeding down the road of self-inflicted complication after complication. I was excited at the chance to educate.

They will not let me say two words, literally, before ranting and raving about nonsensical theories and constant attempts at manipulating me- the nonconfrontational can't we all just get along- brand new nurse. There are definitely some very abnormal mental health issues going on between the two, but I want to keep this as short as possible.

Yes, the word "sue" has come up several times so documenting is obviously important.

I really need advice on how to care for this pt w/o letting this pair of lunatics drive me to tears every night and seriously impede my ability to care for my other patients. I was at work for three extra hours catching up and my pt load was normal, except for this unbelievably abnormal duo.

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Is social work involved? If family is impeding the patient's recovery, someone needs to step in.

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Pt agreed to have DPOA make all decisions no matter what, verbally, to me. But, then, they argue about decisions, every single decision, including such small things as stool softener refusal, and if I follow the pt's wishes the family member gets raging mad at me and the pt. then gets mad and says I should only do what the family says and that's the way it is because he/she is not in her right mind b/c the pt is taking opiods. Please. One or the other is always really mad at me or kissing up to me, sometimes at the same time, sometimes not. They are all over the place and it is way overwhelming for me, but I do not want to request not to have them anymore as I would like to be able to learn something from this as I'm sure I will have many more manipulative people to deal with in the future. (that was one heck of a run-on sentence- I just couldn't stop =) This just may happen to be the most extreme. Hopefully. :)

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That is a difficult assignment for a new nurse.

At the end of the shift ask your charge nurse(or whoever makes assignments) to not assign you that patient next time you work; politely explain that you need a break from them.

There is no easy fix for those family dynamics except to document, not get entangled in their issues and care for the patient the best way you can.

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Pt agreed to have DPOA make all decisions no matter what

...if the POA specifically says the family member make decisions when they are incapacitated, and they aren't incapacitated, then the patient is the responsible party.... a lot would depend on the POA.

In a lot of bad family situations I focus on who is the ultimate reponsible member giving them my total eye contact. If the family members says one thing, confirm it first with the patient as long as you see no legal POA saying otherwise or the POA is not in effect yet. It will also help to discuss this with their doctor if he has seen them previously before hospitalization. Social services and chaplain/priest may also be beneficial. A psych consult if the doctor would agree may be helpful then a careplan addition focusing on the best approach for all toward patient and family may help also. If you feel a little overwhelmed it is not out of reach to ask for reassignment at least temporarily.

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Specializes in thoracic, cardiology, ICU.

Wow. That sounds rough for a new nurse. One thing you pick up along the way is setting limits with patients and families. It takes awhile to build that up. I would get social work involved because they're awesome at this sorta screwed up family dynamic.

If the patients been deemed incompetent, then that's one thing. but if there is a dpoa and the patients still able to make decisions and hasn't been deemed incompetent then listen to the patient.

Don't let them intimidate you because ultimately, you know what you're doing and why. One thing I also do is when there's more than one family member screaming at me I tell them that I'll only talk to one family rep (the health care proxy) and that family rep can then relay the info to the rest of the family. It saves tons of time and trying to talk over people who' won't listen.

This does sound like a really tough assignment, and I think the nurses should share the wealth on this one and give you a break. It happens. Some patients are very labor intensive and it gets exhausting. Others are like this, and you really just need a break to get away from the family drama. I would ask to be reassigned.

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Specializes in psych. rehab nursing, float pool.

I would make a copy of the current days MAR, with both the patient and family member who is POA. Show them the MAR then ask them to agree or not agree as to which medications they are willing for the patient to take. You do not need to agree or disagree with them, if they have questions about a medication, give them the answer give no more information than they are asking for at the time. Once they have gone over the list. I would say " Now that you are both in agreement to this , We should not require any further discussion in this regards. Anything further you can and should discuss with your doctor" Yes, a case manager should probably be involved and would a psych consult be warranted. Most of this can better be answered by the charge nurse of your floor, or an RN who is familiar with the family.

Sometimes the best advice is, when they start this splitting, excuse yourself from the room. If one or the other says or asks something of you which puts you in the middle ask them to first discuss it with each other then come to you.

In most instances nurses really do not have to get involved in it.

Hope any of this helps. I agree it takes time and experience to deal with dysfunction on any level. Do not get in over your head. It can happen very quickly and before you realize it. Chart, chart and more chart.

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Specializes in LTC, Med/Surg, Peds, ICU, Tele.

When people start saying that they might sue then it's time to get your nurse manager or charge nurse involved.

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what kind of a setting are you in

are you a private duty nurse??

if you are in a ltc or acute care you need to get md to meet with patient and poa and let them decide what is going on and then you will have some documentation to fall back on

i like the others suggestion about not swapping this patient between nurses so that one does not get the whole burden

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Thanks for the tips. It is a hospital setting. MD's are all fed up with the situation as well, and since I work nights, it's usually a resident that I am calling every hour for some issue with this pt and they don't even want to bother with it anymore. Pt has been at several different hopitals, continually for a few months, and is a young ADULT with possiblities of older family member keeping this pt sick- get my drift? I hate to even use the term Munch.... well, you know, but it is very hard not to at least consider it in this crazy case.

I suppose my main question, before I go in for next shift, is this - is it what the pt says, or the DPOA says when it comes to refusing meds/treatment? The pt seems capable to me, but not according to dpoa who claims this is absolutely not the pt's right frame of mind since they are on narcs.

I did call for a patient advocate to come and speak with the duo, now I just need to find a nurse advocate for me. :confused:

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A few things...a patient that is so time consuming and stressful needs to be split up amongst the staff so no one has them two days in a row. Thatr's standard where I work. Speak up. No one will think less of you.

If you don't already have your CN involved you need to at once as they are constantly threatening to sue. I would get Social Sevices involved if you suspect the patient is being kept ill...that's abusive. I would also talk to the doctor about a psych consult as it sounds like one is needed.

If the patient is conscious and has their faculties about them you should take your instrucion from them not some verbal order from two loons you have no way of proving in a court of law. I would get help from Risk Management or the hospital attorney on this one ASAP.

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Wow, you are dealing with that much family problems on nights?

If you are having that much problems and interaction on nights, then I pity the day shift nurses.

You are probably not alone in dealing with this family.

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