Non-compliant Manipulative Patient

[cinnybug]

For the past year I have been taking care of a patient who is a paraplegic due to spinal stroke resulting from pain injections to the lower spine. To list all of the diagnoses she has would take more space in this forum than is possible. She is 59 years old and for the majority of her life she has been in and out of medical facilities for various ailments. She also has a history of alcohol abuse. The over arching issue with this patient is that she is highly manipulative and completely non-compliant with all of her care and medications. The PCP has even refused to issue any orders or changes to her med regimen (she frequently would request different meds be added to her regimen). They would tell me that she is a huge liability and needs to be removed from the facility. She has a wound vac, has been treated for C-diff 3 times in the last 6 months and sepsis d/t UTI twice in the last 6 months. She is a diabetic who refuses to eat on a regular schedule and supplements her meals with items she buys online such as candy, cookies, marshmallow peeps, peanut butter, etc. Her glucochecks were typically 400 to 600 every morning. She insists on drinking large amounts of cranberry juice ad orange juice. She self caths but frequently refuses to cath on a given shift and will wait until she produces over 1000cc's (usually 1500 plus) despite education re: autonomic dysreflexia. She also orders online OTC meds such as sudafed (she says to pick her up), Benadryl and Nasal sprays (for her deviated septum) Immodium to harden her stools, Fiber Laxative pills. She also orders cigarettes, E-cigarettes, chargers and has been caught numerous times smoking in the facility ( she is on a nicotine patch) Literally everyday for months I was responsible for searching her room for contraband and documenting all non-compliance. Everyday I had to argue with this patient over her request for Xanax when she had just awoken (usually at noon). I found myself becoming extremely frustrated. When she was confronted with the contraband found she would lie and we would find new"stashes" hidden in evermore insidious places (most recently the false bottom of a drawer that she kept her cath kits in) Yesterday, after I caught her for the 3rd time in two days smoking in her room (in front of her family who then lied to my face about it) she was issued a 24 hour emergency eviction notice. I am trying to deal with my emotions regarding this patient as I went from being extremely empathetic and caring to feeling extremely frustrated and angry over her manipulation attempts and lying. I know she has a mental disorder, Definitely an addictive personality ( I also suspect Narcissistic Sociopath tendencies). I also felt angry over the danger she frequently placed staff and other patients, in as well as the amount of time that she took from the other 29 patients I am responsible for with her demands on my time. And, of course, since I was the main person finding all of her contraband and reporting her she went so far as to tell my supervisor that she did not want me around her anymore. Fortunately, I am off today and she will be removed from the facility this afternoon. I feel emotionally and mentally beat up. Has anyone else had to deal with this type of situation? Am I wrong to feel angry and frustrated?

[CBlover, BSN, RN]

Wrong to feel angry and frustrated!? Of course not. But wow isn't it amazing what a paraplegic can do so secretly despite the impairment!? At least you have an eviction policy. Wish we had that in acute care some days! A pattern I've noticed with some paraplegics is, they do tend to turn to some bad habits just because they really have nothing more to do laying in a bed or sitting in a wheelchair all day. I can think of 2 right now who were also both HIGHLY manipulative. It's sad, but yes very frustrating. I once had one that made up a complete lie about me and tried to turn my supervisor against me with his tall tale. He was known for this and even evicted from a group home he lived in for his behavior. Of course I found that out later.

[cinnybug]

Thank you. Today I am trying to deal with some guilty feelings as I truly believe a good nurse is patient, empathetic and compassionate. What I wrote above is only a small portion of what I have had to deal with. I also had to deal with the frustration and anger from my aides as she was constantly demanding that they tailor their work schedule to her desires. The thing that angered me the most was her disregard for the needs and safety of other patients and staff. Just yesterday while one of my patients who has severe dementia and a broken arm (from a recent fall) was having a sever anxiety attack (resp 36, pulse 122, grinding teeth) in the bed next to her she was constantly interrupting me asking "when is my therapy? Can I have a fresh cup of ice water? Am I allowed to go outside with my family?" I was ASTOUNDED! It took al my strength not to yell at her to shut up and let me help someone who truly needed help!

[Hygiene Queen]

I deal with these types of folks from time to time (gero psych). They are extremely exhausting, and the only thing gets me through a shift is knowing that this patient cannot stay inpatient forever. My time dealing with them is limited... except when nobody wants to accept the patient (shocker!!!) to their living facility... ugh! I always felt sorry for the staff that had to deal with them long term. I remember having some lu-lus in LTC, but your resident (former resident!!!) wins the prize.

Do not feel guilty for feeling less than compassionate. This type of person feeds off of sucking others dry. They want to see you miserable because they are miserable... but we already know this. I just want you to stop feeling guilty! Let yourself enjoy that fact that she is gone! Yes, she's somebody else's problem now, but with her noncompliance, she may do everyone a favor and bow out early... which is probably what she really wants, if you get down to it.

I'm glad she's gone... you deserve a break! Take care.

[cinnybug]

Thank you so much. I was seriously considering therapy for myself! Lol...but instead I joined a gym so I swim laps and take Body Bootcamp classes to work off the stress. I am trying to give myself a break. I kn ow that I am not superhuman. I can now understand why therapists only deal with patients for an hour at a time!:)

[KatieMI, BSN, MSN, RN]

Looks like one of my "problem management" patients.

It is natural to feel frustrated, angry and a bad nurse in general while dealing with this sort of people, but the fact is that one can only take a horse to the river, not to make it drinking. These patients are not imprisoned, they retain their human and civil rights. So, if one of them wants to commit a suicide by eating a pound of candy a day, that's her business and her life.

It is difficult to came to realization that we cannot change some people (and, for that matter, nobody but ourselves) but as soon as you get it, life suddenly becomes easier. As long as the patient doesn't do anything illegal in terms of law (bying and eating candy by pounds is legal as long as she got money to pay), there are only two things you should do. One is just documenting your educational efforts, doc's/family/charge updates and patient being non-compliant. The second one can be a bit tricky in modern climate of "customer satisfaction" and you might need support of your Powers. I am speaking about clear and unequivocal explanation to patient and family of what is going on and what is gonna to happen, so they couldn't tell the judge that "no one ever told us that she could die just from sugar. Everybody around got sugar, so we figured it was all right and nobody told us...". The talk must be clear and with as little sugar-coating and political correctness as possible. Not "a bit of infection in her urine" but "sepsis, or severe infection which often causes death, which came from her bladder because it was not emptied as often as necessary". Do this talk with a witness and document painstakingly. It can save your and someone else's license on the long run.

After this, just remain correct and professional. If there are threats to safety like smoking, state the facility rules and follow them to the point (evicting her was a good move!) If you can only see her once in an hour, state that as a fact of life and do your part. If you will be busy for the next two hours, say that, ask her for the "last wish", then say goodbue for 120 minutes. Make daily schedule and keep it that way as much as possible. If there is only X drinks/ice creams/etc she can get, write it on a piece of paper and give her, marking every one given. If all nurses and CNAs follow these rules, many of these folks come back to (relative) normal with amazing speed, the rest at least mellow a bit.

P.S. I'd seen many such patients delaying self-caths till their bladders were about to burst, and really wanted to know the reason. Many of these poor souls were and are intelligent enough to get an idea that sepsis is not fun, and yet they continue to delay caths. After cautious talks two issues emerged: high cost of supplies (usually solved by a good case manager) and what some of them described as "pleasant" feeling while quickly emptying overfilled bladder. They just liked that feeling, that's it. I do not know if it might have something with sex (of which many of these patients are deprived forever) or some residual sensation anomaly but the fact was that they just wanted to do self-caths that way.

[iluvivt, BSN, RN]

I like what KatieIM had to say because it is so very true! Long ago I figured out that I would NOT let the manipulative crazies get under my skin and how to counteract such behavior. I did a lot of reading on human emotions and behavior my first four years as a nurse. I had such a fabulous education but what I did not have were the tools to deal with the immature, ignorant,abusive, manipulative, controlling, unstable bipolar,angry, and the never ending parade of nut jobs! It really took me a few years and a lot of practice to effortlessly deal with all these types. The key is is to not let them ruffle your feathers at all. They either are going to follow the plan of care or they are not. I will not be begging or urging them but I will be happy to provide the facts, reassure them and happily assist those who do want to get better. You should NOT be paying the price in stress and wasting time and resources on patients such as this. You must document the patient's actions and refusals and report all noncompliance to the provider. Then go help those who do want your help and support!

[Hancock330]

I'm guessing that there were many staff meetings regarding this patient. However, you don't say whether there was an agreed upon plan of care. While nothing should be posted in the hallway, you might try a poster board in the resident's room outlining the plan of care. The diet instructions should be clear; the frequency of staff visits should be clear; a specified time when the aide will be available to assist with hygiene should be clear; etc. Unless the resident has been declared incompetent by a judge, searching her room for "contraband" (unless it is illegal to possess) is probably not legal. If the resident would consent, a videoed session with her regarding the effects of her diet choices and her unwillingness to self-cath as prescribed might protect your license and the facility from the almost certain complaints (and probably a law suit) from her family immediately after her untimely death. Having a place in her room, near her bed, where staff members could initial while in her room MIGHT help -- although an electronic record would be much better because it is much more difficult to falsify (that is, most of us would be unable to go into the record and change times or dates -- on a page to be initialed, a person can just initial all the times at the start or end of a shift). I wonder if it would be legal to create a VERY distinctive clock showing date and time in a resident's room so staff could create a photo record (with cell phones, for instance) showing when they were in the resident's room? Not at all sure about that. NOTHING you can do -- nothing any of us can do -- will change this person's way of interacting with the world. We simply CANNOT fix her because only she can fix herself. We CAN set limits and we can enforce rules. I'm sure many attempts were made to make it easier for her to comply with health maintenance activities. I'm assuming staff made many attempts to get her out of her room and socially involved with other residents and mentally active at something other than sowing hate and discontent. I'm glad your facility was able to evict her. I wish I could believe she might have learned something from her experiences at your facility. Unfortunately, I doubt she has done more than increase her store of things to be unhappy and angry about.

I hope you never again have to deal with a resident who is this challenging. Best wishes for a long period of only normal challenges in your work place.

[Pythinia]

That's a lot of descriptive words you use on a patient... to deal with the immature, ignorant,abusive, manipulative, controlling, unstable bipolar,angry, and the never ending parade of nut jobs!

Why don't you find another vocation?

[heron, ASN, RN]

That's a lot of descriptive words you use on a patient... to deal with the immature, ignorant,abusive, manipulative, controlling, unstable bipolar,angry, and the never ending parade of nut jobs!

Why don't you find another vocation?

Oh, dear ... another enforcer heard from:blackalien:

There is nothing professional or healthy about allowing oneself to become a doormat - or in trying to pretend that dealing with these behaviors is not emotionally draining.

So, if you disapprove of the way the pp feels about the way some patients try to treat her, then why don't you find another site to troll.

[Hygiene Queen]

That's a lot of descriptive words you use on a patient... to deal with the immature, ignorant,abusive, manipulative, controlling, unstable bipolar,angry, and the never ending parade of nut jobs!

Why don't you find another vocation?

Are you even a nurse?

[martymoose, BSN, RN]