noncomplian patient...what to do?

[chenoaspirit, ASN, RN]

I have a patient with A-fib, venous insufficiency, MASSIVE venous ulcers on her legs, and rotting fingers. I make twice-weekly visits to change UNNAs boots. She is supposed to elevate her legs, wear oxygen at night, wear her unnas boots. When I go for my visit, she has taken off her unnas boots, she hasnt worn her oxygen and she REFUSES to elevate her legs, stating that elevation makes them hurt. She wont go to her MD appts, she complains all the time. Now her fingers are literally ROTTING off her hand. They are black! Her body is oxygen depleted all the time. I have done teaching over and over and over, explaining the importance of wearing her oxygen and being compliant. She hates the unnas boots, which Im sure I would too, but I keep telling her that her legs will end up infected or amputated if she continues to be noncompliant. Im tired of arguing with her, Im tired of "wasting my time" by doing all this wound care and teaching and blood draws, etc. I love all my patients and want to help them all, but she is unwilling to do anything to help herself. I want to just stop going because the visit exhausts me, but I wouldnt be able to live with myself. Ive talked with the doc, he feels the same way I do, but what do we do? I document carefully. I walked in her house Thursday and she was asleep in her recliner, legs not elevated, no oxygen on, her O2 sat LOW. I woke her up and showed her what her O2 level was, she didnt care. What would you do? Her response was "I can only do what I can do". Well she isnt doing ANYTHING! Please give me advice....

[tewdles, RN]

Do you think that if she continues on this path she might be dead in 6 months? Talk to her doc about a hospice referral.

[nurse42long, RN]

Actually if this is a Medicare patient then the documentation of continued noncompliance makes her ineligible for HH care. Check with your Clinical Manager or Supervisor and see if continued visits are even warranted. When Medicare audits then they will look at the documentation and determine if payments made need to be taken back. Also does this pt have a psych diagnosis? Is she depressed and possibly suicidal? Is she capable of rational decision making? Does she have family or a caregiver involved? I would document, document, document everything you are doing to teach and reinforce to this pt. It could end up bad.

[chenoaspirit, ASN, RN]

Hmm, now Im even more worried...

I guess I need to talk to my manager about it. Im just so frustrated!

[erroridiot]

Ultimately, the patient has the right to live like this.

Even with a court appointed guardian, the patient has the right to refuse treatment in the majority of cases.

Document the incidents, notify the physician and document, notify the supervisor and document and if the case is Medicare, it will be time for discharge.

If you can not reach the physician or receive no response from the physician, advise the patient to see a physician, go to urgent care or ER and document it all.

[caliotter3]

If you no longer feel like dealing with this, remove yourself from the case. The agency can discharge her for noncompliance, many agencies do, but that depends on them and how badly they want the income from the case.

[KateRN1]

Has your patient had a social work visit? Sounds like way past time to refer to MSW. I would also consider a hospice referral, as mentioned above. Does the patient have family members who would be willing to get involved with her care? Does she have the capacity to make prudent judgments?

[chenoaspirit, ASN, RN]

Her granddaughter is involved. She is there everyday to set up her meds for the day. She argues with her as well to get her to do what we can. The patient wants to get better, she just refuses to do anything to get better. She just expects that if she ignores it, it will go away. I hate to discharge her, I know what will happen to her if I do. But at the same time, a visit to her house exhausts me. I dread going so bad. When I was off work for 9 weeks after my spine surgery, none of the nurses wanted to go see her. It was so bad that one time her case got passed from one nurse to another and her visit was missed. I know thats bad on the agency's part, but thats how bad the patient is. I havent talked to my manager yet. Im not sure about a hospice consult, I dont think the md or patient would be willing to do this. What would be my reason for a MSW visit? I mean, what would I put on the interdiscip referral as the reason? I need help. Thanks.

[nurse42long, RN]

Sounds like you know what to do, but you have bonded with this pt and don't want to do it. That can be draining and can lead to burnout on your part. You can't solve her problems, she maybe doesn't want her problems solved. If her problems were solved she wouldn't need you. You should take yourself off this case. Could it be that you are (in an unconscious way) allowing her to continue to be noncompliant. Sometimes (particularly in HH) pts get more than nursing care from their nurses. Some pts need the visit more than the care. We have to be particularly vigilant in HH not to get overinvolved in our pt's lives. It's not good for us or for them.

[berube]

this just happened to me this week,,,,,long story short....stage iv on sacrum,,pt refusing every recommendation, each visit i would document pt noncompliance,,even told the pt that he had the right to refuse, but that medicare would not continue to pay.............very frustrating situation,,,family always yelling etc....i would update my manager each visit,,,called the MD, MD said discharge as you can not help a noncompliant pt.! so i believe it is in the documentation. good luck, i share your frustration.

[caliotter3]

this just happened to me this week,,,,,long story short....stage iv on sacrum,,pt refusing every recommendation, each visit i would document pt noncompliance,,even told the pt that he had the right to refuse, but that medicare would not continue to pay.............very frustrating situation,,,family always yelling etc....i would update my manager each visit,,,called the MD, MD said discharge as you can not help a noncompliant pt.! so i believe it is in the documentation. good luck, i share your frustration.

Yup. Document until the decision is made to discharge. Or leave the case so someone else does the same.

[KateRN1]

What would be my reason for a MSW visit? I mean, what would I put on the interdiscip referral as the reason? I need help. Thanks.

Referral to MSW to evaluate for patient's ability to comply with plan of care, knowledge of community resources, and long-range planning.

Goals: patient's ability to comply with plan of care will be evaluated, knowledge of community resources will be evaluated, and long-range planning will be started.