Non Compliant Wound patient

[Katwel]

I am a home care nurse and have been involved with a wound care patient that is so noncompliant.....My 40 something paraplegic female was found to have a large stage IV wound on her sacrum. This patient has failed to go to wound MD appts, doesn't follow direction when it comes to keeping pressure off her wound and keeping area clean and dry. She will be seeing a new Wound/Plastic surgeon his week, but since I have seen her she has develped two stage II wound in adjacent areas. The patient is in the social work system, has to cg 12 hours a day, but clearly needs to be in a nursing home for more consistent treatment. How do you deal with a patient who clearly doesn't get it and when your consistent teaching goes on deaf ears. I am very frustrated and don't know how to deal with this sad women.

[rn/writer, RN]

Your all so right, and deep down, I know this but, its so upsetting when you try to do things for patients and want a positive outcome, it just makes you feel like you failed. I will continue to do what I can, and of course continue to teach, but I know we can only provide the information and hope that in the end the patient makes the right decision.

You said that you want a positive outcome and that you feel like you have failed. But this isn't about you.

This isn't about compliance either.

It's about connection with someone who is lost and sad and clinging to some semblance of control in her life, even if it will cause her harm.

Yes, you document, but you also set aside your goals and ask your patient what she wants. And you do it without judgment or exasperation or anger or disgust.

I would suggest approaching this woman with an apology for any assumptions you have made about what is going on in her mind. You do this, not because you are an inconsiderate person (you actually sound like you are thoughtful and caring), but because we in the health care profession are very good at deciding what's what and operating in the supreme confidence that both we and the patient are in agreement about what is best for them. With that in mind, deviations from the expected course get labeled non-compliance, and let me tell you, anyone who deals with chronic health problems hates that word with a purple passion.

Non-compliance with what? Goals and instructions someone else chose.

What about sitting down with your patient and just asking her flat out, "Mary, are you happy with the way things are now? Tell me something that would make your life better. I don't want to keep harping on you to do things you don't want to do, so let's see if we can figure out something you do want and then we'll look at how I can help."

You don't have to sugar coat reality. You just have to be kind in delivering the truth. "I worry about that wound of yours. I think maybe you do too. Tell me what stops you from doing the dressing changes. Help me understand what gets in the way."

Really listen to the answers. And then work with them.

At some point, you may have to speak about harsh realities. Even this can be done with a caring spirit. "Mary, I think the surgery would be a big step forward for you, but right now, you're not a good candidate for it. There are some things you and I could work on together to improve your chances, but I don't want to force anything on you."

The trap that many of us fall into is picking up the other end of the tug of war rope and getting into an oppositional dance with these folks who really need to be doing battle internally. If we find a way to stay on their side of the rope, we not only multiply their strength, we apply that mighty pulling power against the real enemy--the disease, the depression, the overwhelming circumstances.

So many chronically ill people are trying to tell us that we can't make them do anything. And they are right. That's when we need to ask them what they want. What hopes do they have? Have they already decided there is no hope?

If we can find some point of connection, some spark of life that can serve as a reason to take better care of themselves, this is worth more than all the lectures in the world.

We meet them where they are and earn their trust by listening to what they tell us. We respect their autonomy, ask how we can assist them in meeting their goals, and with their agreement, help them to find their way to a healthier place than where we found them.

[CoffeeRTC, BSN, RN]

She will probably refuse care in the LTC or rehab center too.

As the PPs discussed...get to the root of the problem.

[highlandlass1592, BSN, RN]

Your post is spot-on. I deal with this quite a bit with the heart failure/cardiac surgery patients I encounter. Many nurses I work with get flustered when patients don't comply with "our" treatment plan. Seems many times the MD's too forget an important point: people have the right to make a bad decision. Doesn't mean they aren't educated, just that they don't agree with what we are trying to do. Our job then becomes one of support, trying to figure out what they want and how to best achieve it. Trying to figure out how to give them the best life possible within the parameters they are willing to work within.

Just lost a heart failure patient this weekend. A sweet man but determined to have his care "His" way. It was sad, especially more because if he had just changed the way he managed his care, he could have lived for quite a while. But he knowingly made a decision that he wasn't going to do things our way but his. I can't begin to tell you how many nurses came to me upset about what he was doing. As caregivers, when we work so hard to keep people alive it can be difficult to deal with pt's who don't make the decisions we think they should make. But that's ultimately what we ARE working for...giving our patients the right to make their own health care deicisions, to live their lives as they feel they need to. As advocates, we sometimes need to be reminded of that fact.

[grannyrn65]

I have read the comments with interest as I was once a non compliant patient. I accept responsibility for what I contributed to the worsening of my chronic disease but I would like to share a few things. I agree with the post from the assistant all nurses administrator's comments. I went thru some of the same problems in acceptance, why me, why now, I don't have the time to deal with this, I want to eat what I want to eat. I could easily substitute any other chronic disease and the same reasons for any non compliant patient. I had to reach a point where I wanted change. What might have helped me sooner was all the nursing staff and all the physicians who 'taught' me, had also referred me for some psycho-social help. None of them did. They just told me what they expected me to do, to eat and ignored finding the reasons for my non compliance.

Non compliance is not a simple problem to deal with. And patient education involves much more then just teaching the proper care. As a nurse, I am not only the teacher but I am the first person who deals with all the issues involving a patient. I am the one who has the first opportunity to determine what the patient knows; what his/hers level of education is; what help is available; what home issues are there; what help there is available to the patient; are there any religious or cultural impediments; to address a few of our responsibilities. I say ours because they are all of ours. As inpatient we have allowed our role to be decreased by short staffing, lessing our times to spend with patients, and abdicating our responsibilities. To pass the responsibility on the the next group of nurses, who have their own problems and issues and lack of staff.

We need to take back our responsibilities. We need to stop taking what 'they' dish out to us. Until we do, we will all ways be treated as the second class citizens we are. We all learnt the necessary lessons in our programs. And we slowly started making those decisions abdicating our roles.

My primary care physician keeps asking me when I am going to come out of my retirement and start working again, citing a need for those older nurses that have the necssary skill sets. I just shake my head and tell him H*** will freeze over first.

Sorry

GrannyRN65

sitting back in her rocking chair and reading a good book

[Katwel]

Thanks to all who have shared their advice. I feel bad that when I have to deal with my so called problem patient that it gets me very depressed and I feel ineffective in providing care. When I saw her the other day and tried to understand how can I help this poor women, she just snapped at me again, and said my wound won't heal till I have surgery, my response was, I just want to try to keep what we have from getting worse. When someone mentioned about pycho-social help is valid, but I fear this patient has more serious mental needs. I also feel I have been asking for help from my supervisors and all I hear is we need to have a patient conference about her, well we have done that in our weekly meeting as "Problem Patient" but I still come out feeling helpless............