Non-compliant home care patient with stage three decub

[sticknurse]

Hello everyone, I am working with a challenging young man who suffered a spinal cord injury. He is 27 and preferes to sit up in his wheelchair for hours at a time despite our admonishments. I am looking for advice because he's refusing interventions and education attempts we've made so far. I am trying to find a way to impress upon him the risks he's taking and help him understand his risk. We also suspect ( I work in the home with another nurse) that he may be abusing his prescription valium as well. He is a recovering addict by his own admission and sometimes apprears to be "under the influence" of something when he is assessed. He also refuses vitals and asks us "don't write that I refused vitals." A nurse who works with him told me recently he threatened to fire her if she reported a new area of pressure she noted to the doctor. He basically told her if she called the doctor she need not return. What do you do with a patient like this? There's virtually no family support in place, his own mom stated "I don't want to be his back-up caregiver anymore, I've had it with his verbal abuse and manipulative behavior." (Mom is a social worker!) What would a prudent nurse do?

[ohmeowzer RN, RN]

i wouldn't want to be his nurse either. but i would do what i had to do to cover myself legally. if he didn't want me back.. so be it... it is his right to refuse any treatment , but .. cover yourself.. if he ever goes septic from those wounds, you want to be have your bum covered.

[sticknurse]

I am providing him with educational material which will explain his risks, and charting all the responses I get when I attempt to enlighten him. He's very intelligent, but stubborn as well. We are concerned that one of his wounds is infected now and he's refusing to go to the doctor so far. I've never taken care of a more challenging patient....thanks for the advice!

[kukukajoo, LPN]

Time for a psych assessment if you ask me. If he is being noncomplaint, combattive and manipulative.... and possibly abusing meds I would definately refer him for one no matter what it is he wants himself!

[fultzymom]

In a case of a non-compliant patient, I always make sure to document every thing that happens. And you have to report everything to the doc, even if he requests that you never come back again. Is he going through some psych issues that need to be dealt with? It must be hard to be so young and find yourself in that kind of situation. Maybe he needs to see a therapist for someone in the Mental Health Profession.

[Nazarite]

If his own mother who is a social worker has established her boundaries and refuses to deal with him, then he is definitely in trouble...

If he says he is in recovery but is suspected of abusing his Valiums and you or someone knows or can verify it because he comes up short every month on his pill count, etc..., someone (don't know who) should confront him and tell him he's full of crap and in relapse (does he have a sponsor or any 12 step friends?)......sorry but i have prior experience with all of this and coddling and telling people in recovery what they want to hear rather than what they need to hear is a form of enabling.......and using under the guise of 'it's a dr.'s prescription' is a line that is an old rationalization used by addicts for ions...

I took care of a patient years ago who was 32 years old when I came to care for him with severe type 1 diabetes, he was partially blind and had severe neuropathy when I first took care of him....basically acted like your fellow, except in a nicer manner, thank God...but myself, the agency, his mom, etc couldn't force him to do anything....well by the time he died at age 35 he had a heart attack, was on peritoneal dialysis, lost both legs, (in that order) and basically died in what i would term "suicide by noncompliance".....it was a shame too because he really was a sweetheart....he just couldn't get past all his losses, dwelt on them, and no matter what interventions were attempted continued to be non compliant....i guess his attitude was i'm going to do what i want to do and enjoy what i can, but unfortunately it was at his own detriment......i always have to wonder how much longer or better things could have been had he been compliant....but i'll never know...to quote frank sinatra, he did it his way.....

sad, but bottom line...it was his right....

i hope someone can get through and intervene with your patient before it is too late.....

you know that tv show "Intervention" on A&E? well the disabled are not exempt from that...maybe a group of family/friends/caregivers/people he may know in recovery could stage one....don't know if an addictions counselor is available but it could be a starting point....addicts need to be confronted.....

hope this helps, and tell him someone is praying for him:)

[caliotter3]

Same as the others have said, document everything. But do not follow his instructions to leave out refusals and to not call the doctor. Document his refusals. Call the doctor as you would for any patient. If he fires you, then that is what happens. I have seen this type of patient who refuses the world, then when they get the idea, they sue everyone involved for their care because of their poor condition, that was brought upon by their own noncompliance. You have to be mindful of your license. And if he is suspected of abusing his controlled substances, then how is he doing it? Doesn't your agency use an accountability record? He needs to be spoken to by the Director of Clinical Services regarding his eligibility for future care. All the contracts that I have seen state that a client may be discharged from services for reasons such as you describe.

[Blackcat99]

When I worked at a LTC there was a non-compliant lady who had a decubitus ulcer. After her death, her family sued the LTC facility and won their case. :oApparently, the nurses had not done enough documentation about her refusal of decubitus care.

[RN1121]

If he is made aware of the ramifications of his actions and still insists upon doing what he pleases, that's on him.

If you and other caregivers have documented his non-compliance and disinterest in his plan of care, then you have covered yourself from his ignorance.

I've always thought that people will do what they want to do when they want to do it.....similar to smoking and losing weight, I guess.....

If your not ready to take responsibility for the decisions you make, then be ready to handle the consequences, at any cost...

Your a nurse, not Superman! He is making his own informed decisions, and he has every right to do so...

Just know you can't change anyone who doesn't want to change....

[nightmare, RN]

This guy is obviously in denial and probably depressed.He cannot feel the pain so it is not there.He's probably given up on life and doesn't care any more.(Well that's just a thought anyway)

[sticknurse]

Thanks to all for your informative responses. I am "covering mine" with education and lots of charting! I also try to let the new nurses (he goes through them like cheerios) what they will be facing. I don't work for an agency so there's no policy i can use to get out from under this. I work for myself, and as a "prudent nurse" I try to do what I can to make him aware of any possible consequences he may face if he continues to refuse care. As far as a lawsuit claiming staff didn't assist him, well, he has a long history of this type of behavior from what I gather. He's been in and out of rehab, mom is fed up, dad is in prison, and friends that I've met are questionable as far as intervention potential....thanks for the advice. I will keep trying to convince him to change, but I fear to no avail.

[lorster]

Sticknurse. I took care of a spinal cord injured man for 11 years. The first three years for an agency and when I quit the agency, he called me a while later and asked if I could work privately for him which I did for the next 8. He was injured when he was 25 and passed away when he was 49. During that 11 years, I tended to more Stage 3 and 4 wounds than I care to remember. Not only did he have wounds, he had burns constantly from smoking, and tending to a wood stove that was the only heat source in his house(he lived alone). He also drank heavily. He sat in his chair for days at a time. He refused to be bathed, he refused dressing changes some days. I would go out and sit for 2 hours at a time, waiting to assist him into bed to clean him up and do his ischial dressings only to be refused, cussed at and items thrown at me. I allowed him to refuse as that was his right but not without letting him know the consequences of his refusal. He also refused to let me do foot care which is so vital with spinal cord injured people. His feet were caked with dry skin and each admission to the hospital brought questions about the care he was getting at home due to a horrible body odor, from MRSA infected wounds. I also worked at this hospital so the staff knew that this was not the type of nurse I was. It was the most frustrating years of my life but in many ways so rewarding. I often wonder what I could have done different but I'm not sure I could have changed his course. He told me he didn't want to live in his body and his refusal was a quicker way out. I tried to get him to counseling with no success. His primary MD had many talks with him. It did no good. Fortunately he had a family who loved him and supported him no matter what decisions he made. Things got so bad that I told him that I could no longer be his nurse and things changed. (I didn't do this as a threat, I felt that I was not the nurse he needed) I hired another nurse to come in and help, hired home health aides which he had refused prior. I set up a support network and we kept him busy and he was required to be 100 percent compliant through our personal contract. I'll say that the last two years, he was at his healthiest of all those years and he stated he felt better. Unfortunately he got a bad case of pneumonia in 2004 and succumbed to it. I don't think you are going to change things but just know that you are an extremely important part of his life even if he does not admit it. You do make a difference. Let him know that he has the right to refuse but you are legally obligated to document the refusal as well as educate him on the consequences. He is angry and much of this anger, he may never resolve. All you can do is the best job possible to make his life a quality one.