Nursing judgement in dealing with difficult patients.

Esme12, ASN, BSN, RN · May 30, 2014

You will attract more bees with a little sugar.

Just tell them...this is what works for me and my patients. I get compliance. You do your thing I'll do mine.

Then go about your business.

Trauma Columnist · May 30, 2014

Extremely dangerous practice. These pts have needles in place that if they become dislodged, can cause exsanguination in just a few short minutes. Allowing your pts to leave the facility is a recipe for disaster and I'm positive it's against your facilities' policies. You are placing your pts lives as well as your license in jeopardy!!!!

FransBevy · May 30, 2014

True, Trauma, but right now the two smokers hace CVC's and I've informed them that when their fistulas mature the party will be over and I'll see about nicotine gum. Both of the current crop of difficult, recalcitrant babies are still fairly new to dialysis and one, while still young wants to sign off and has missed a week of treatments because he felt it just wasn't worth it. It's difficult.

SubSippi · May 30, 2014

Your manager may support you now, but if something happens to a patient while they're outside smoking you'll be the one to blame. If the manager really agrees with this practice, then policies should be changed to allow patients to go outside and take breaks.

The other nurses may be irritated with you because it makes their job harder when they try and enforce rules.

You may feel differently than I do, but in my opinion, if a patient doesn't want to be compliant with their treatment they can go on home.

Trauma Columnist · May 30, 2014

All a pt has to do is trip, fall, pass out, etc., and you are liable. I sincerely hope you rethink this strategy. If you work for one of the top two, they will NOT support a breach in policy.

You are not helping these pts by allowing them to smoke during dialysis. Does your state have free smoking cessation? IL has a program that provides nicotine patches for smokers for FREE! Its really worth it. Dialysis pts can take chantix but at such a low dose that it often is more emotional support versus physical support.

Does your APN and med director know and allow this?

FransBevy · May 30, 2014

My FA knows but I can see your points very clearly. What do you do about thise patients who just don't seem to get it? My patients always finish their treatments and never sign off and their numbers usually improve when I have them frequently. The other nurses don't want them, frankly, and the AMA right is pretty high with the rest of the staff.

It's pretty freaking difficult. Arrgghhh! Thanks

iluvgusgus · May 30, 2014

You can lead a horse to water but you cant make them drink. I think you may be too emotionally invested in people who did not, for years, take care of themselves, and still dont, and they are now living with the consquences. When I worked on a M/S floor the dialysis pts were, by far, the most non-compliant and grumpy pts I took care of. They were always wanting to leave AMA, were verbally abusive, refused lab draws, refused vital signs, refused to adhere to carb consistent diets, and would also want to go downstairs to smoke when the MDs did not want them leaving the unit. Some of them would skip their dialysis for a week, then decide to go back for dialysis to find out where they were being treated would not take care of them anymore because of their non-compliance, so they would come for inpatient dialysis for WEEKS on end while SW tried to place them with a center. They also would be in the hospital for amputations and still make a fuss about their carb consistent diet and yell at the nurses " im not diabetic!" So, yeah, its hard to not be judgmental when 99 percent of them act this way. Just tell them no. Would you rather let them manipulate you for a drag or keep your license?

SmilingBluEyes · May 31, 2014

NEVER let patients leave the building to smoke, etc. SO dangerous. If they want to go and smoke here, I tell them they must sign AMA, I then notify the MD and terminate treatment. You are asking for a lawsuit. Remember, people on dialysis can be very unstable in the midst of treatment. This is why we return their blood and get a good set of vital signs before bathroom breaks. If they telling you they want a bathroom break, but go out to smoke instead, get your manager, the MD and social worker involved. You are asking for it if you knowingly let them go outside during tx; no doubt breaching policy, as mentioned above.

I understand your good intentions, but be careful to always have appropriate boundaries with your patient. You cannot fix them, their poor lifestyle choices or other issues like these. I think you need to have a good conversation with your social worker as soon as you can about establishing appropriate boundaries. You appear to be struggling with this. Boundaries protect you and your patient, both.

madwife2002, BSN, RN · May 31, 2014

While I commend the empathy you have with your patients, please take heed of what other members are advising you to do. The consequences of the patient having some sort of event while outside smoking is high. These are very unstable patients especially if they have a CVC and are within first 90 days of dialysis

Christy1019, ASN, RN · May 31, 2014

I don't know your facility's policy but what if you recommend for them to bring one of those e-cigs for their appointments? There are inexpensive ones for sale at gas stations.

wooh, BSN, RN · May 31, 2014

I can imagine your coworkers are annoyed if you're making their job harder. You may prefer catering to your patients over your license and facility liability. Your coworkers have every right to value their license and their job. You are making it harder for them to keep those because you make them the bad guy when they enforce the rules. "Why can't I? FransBevy lets me!!!"

Life sucks on dialysis. But it doesn't give a dialysis patient the right to threaten your coworkers' licenses and jobs. Which is what they do when they break facility policies and violate best practices.