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?

[SuesquatchRN, BSN, RN]

"Suicide by non-compliance."

I think that nails it.

[GLORIAmunchkin72]

sticknurse, don't feel bad; you're not alone. We have a resident who refuses to take baths or showers. She is "with it" enough that when she asserts her wishes we respect them and do all the right things such as nicely talking to her about the importance of taking baths, charting, etc...but 2 or 3 days you can't get past the smell and something has to be done. She is already taking psych meds but something is definitely lacking.

[humility]

When all else fails~Try God! Treat the patient; mind, body, & soul~You already know his physical ailments, now attend to his spiritual ailments~

[mscsrjhm]

His spirituality is his business. Inform him of the consequences of his noncompliance with medical advice, chart that you informed him, and leave him alone. Talk about sports, politics, his shoes...

I don't have any problem with non compliant clients/patients. Treat others as you would want to be treated. If they refuse, inform them, chart, and go on about your business. I don't appreciate people trying to talk me into anything- be it medical treatment, religion, spiritual issues, etc, and I'm not going to do that to other people.

Life, liberty, and the pursuit of happiness. Maybe his noncompliance is what makes him happy. Not our jobs to "fix" him- not our place to decide what makes him happy. If he dies due to noncompliance, then he dies. It is what it is, and is nothing more.

Leave it alone.

[diane227, LPN, RN]

Who is paying the bills for this guy? Are you hired as a private duty nurse or do you see him as part of home health services? If he wants to fire you for doing your job, then so be it. You have to report what you see. You can't make this guy get better and agree to the plan if he does not want to. He probably is abusing his meds. I would say keep documenting what he is doing and what he says and have someone review his chart. Perhaps they need to pull care from him completely.

[Bettie P]

He is used to practically being begged or cajoled into accepting services, and I'd bet he enjoys the rise he gets out of the nurses. I would stop giving him the pleasure of being the center of the world. Immediately upon refusal of services or a request to not document appropriately, I would state, "It seems that you do not want to receive nursing services today, so I will leave." Then leave, documenting why.

He also needs to be asked to refuse services in writing whenever he refuses an ordered treatment. An addict would not be above trying to manipulate things so as to make it seem like nobody offered to do things for him.