Nursing judgement in dealing with difficult patients.

[FransBevy]

I've 30 years of nursing experience in various specialties (surgical, ER, tele) who's been in dialysis for 2 1/2 years. It's not my dream job but I work hard to help my patients make the best out of the rotten hand they've been dealt. One thing I do an excellent job at is withholding and suspending judgement on the 'lifestyle' choices my patients make. I want them to live, I want them to feel valued, and I want them to feel that dialysis is as important as breathing. If I can keep them alive and well so that maybe, one day, they'll see the light and start taking charge of their own health I'll feel like it's been worth it. Because of this I frequently get assigned the psych or addicted patients because I love the challenge and because I can usually get through to the occasional 'outlier'.

As such I occasionally will allow a patient a 'bathroom' (ahem, cough, cough) break where they'll grab a quick cigarette. I make them promise to return and they always do. I increase their UFG to accomodate the extra blood return and I've yet to have a patient not return. My manager knows what I'm doing and we both agree that complete dialysis is the ultimate goal.

The problem I'm having is with the other nurses and techs who openly disapprove of my 'spoiling' and 'giving in' to my patients. They're always going on about what my patients are 'getting away with' and how I'm letting them run the show. They're the most harsh, judgemental crowd I've ever worked with. I'm an experienced RN who's worked with all types for years. I know I'm being a bit manipulated but so what? My patients always improve their URR's and THEY SHOW UP!!!

So what do I say to these nosy Parkers who always have to have an opinion on how I treat my patients? I'm tired of them.

[FransBevy]

Thank you everybody. I've told my patient no more breaks, I've stuck by it and he now shortens his treatments but what can I do? It's his life.

On the idea that dialysis patients are very often there by poor lifestyle choices: I'm about 15 pounds overweight and I don't exercise. I know better but hey! my life's so hectic and crazy that I don't treat my body right.

So, I'm the last person who can pass judgement on my patients. I educate and educate but at the end of the day it's a case of, 'Nurse! Heal thyself!', I'm afraid. Once again, Thanks!

[Guttercat, ASN, RN]

If you think that is bad, wait until the artificial kidneys come out, it will be wonderful for us and you will be on the unemployment line.

I truly hope the artificial kidney technology progresses. The day that the need for dialysis ends will be a great day. I will happily stand in that unemployment line.

[Guttercat, ASN, RN]

They have to make the decision whether or not you like it or do not like it. We are adults, as such we are not your children.

All we as dialysis staff can do is educate. The decision is up to the patient. You are correct, patients (and that means any of us in any medical situation) have the right to refuse a plan of treatment. That said, it's also not on us to encourage or enable dangerous behavior while a patient is on treatment.

If I go to a dentist appointment, and the dentist has me on nitrous gas for a tooth extraction, what do you think the dentist will say if I want to get up and take a smoke break in the middle of the procedure? I would expect the dentist to refuse my request. If he or she did not tell me they would not accommodate this request, I would find another dentist. That dentist would not be practicing with my best interest and safety in mind.

You make an excellent point about the odd paternalistic dynamic that can seep into the ESRD/dialysis scene. It does happen, but please don't let your anger and frustration overshadow your passion for patient advocacy, or your common sense.

[FransBevy]

I come from a surgery/ER background so I'm still getting my footing in this chronic care thing. There's a truckload of difference between the "treat 'em and street 'em" dynamic of urban hospital nursing and chronic dialysis nurse/patient relationship. It's all nursing and basic nursing principles will always apply but the intensity of the interaction has to be dialed down a notch in this setting. I'm growing to like it but sometimes it seems like transitioning from a race car driver to a taxi driver.

[SmilingBluEyes]

Disallowing people to go out smoking during treatment is NOT poor customer service. It is operating safely and within policy. They are not my children and I don't treat them as such. But I deliver safe care, and don't let patients triangulate (good nurse versus bad nurse) that doing such things as allowing a person to go out smoking will bring about. If they want to go out to smoke,they go AMA.

[kdunurse]

They have to make the decision whether or not you like it or do not like it. We are adults, as such we are not your children.

Absolutely. However, it is completely appropriate for the dialysis unit to have a policy of not allowing pts to get off dialysis for a smoke break. In that case, the pt can decide to do dialysis OR smoke, not both. I have several dialysis pts who frequently ask to leave early. I make sure they are aware of the consequences, have them sign the release, then take them off without arguing. Dialysis pts do have rights, but they don't extend to placing the unit at risk or inconveniencing other pts.

I will also share that as a taxpayer, it find it extremely frustrating to have to pay (literally, through Medicare funding) for the consequences of the poor choices of others. Of course, this doesn't apply exclusively to dialysis pts....

[NDXUFan]

For everyone's knowledge, I have very bad asthma, since my freshman year in high school, 31 years of asthma. I absolutely hate smoking..... Smoking on a treatment is a fire hazard, that is not something I would tolerate. One of the reasons that dialysis patients have issues is because they do not do their treatments and the dialysis companies are simply not giving enough dialysis. Honestly, in a number of cases, I do not have sympathy for either party. No, letting the patient put a dialysis unit at risk, no way, Jose. Making other patients constantly wait, no way. I do my treatments every day and get rid of my fluid and I am still coughing, I have a breathing machine, so I do not have to go to the ER and charge the taxpayer a small fortune, some on dialysis need to use their heads. Honestly, I hate the ER and do everything to avoid it, awful and yucky.

OR these fools who have something wrong with them, they wait six months and then go to the ER, their care is paid by us, the taxpayer. They could have gone to the primary care, paid much less, had it taken care of, and been out in 20 minutes, how stupid.

Uffe Ravnskov, Professor of Nephrology and Professor of Chemistry, Ph.D.:

That problem was solved by Dr. J. C. Paterson from London, Canada and his team (27). For many years they followed about 800 war veterans. Over the years, Dr. Paterson and his coworkers regularly analyzed blood samples from these veterans. Because they restricted their study to veterans who had died between the ages of sixty and seventy, the scientists were informed about the cholesterol level over a large part of the time when atherosclerosis normally develops.

Dr. Paterson and his colleagues did not find any connection either between the degree of atherosclerosis and the blood cholesterol level; those who had had a low cholesterol were just as atherosclerotic when they died as those who had had a high cholesterol. Similar studies have been performed in India (28), Poland (29), Guatemala (30), and in the USA (31), all with the same result: no correlation between the level of cholesterol in the blood stream and the amount of atherosclerosis in the vessels.

ND:

One of the issues is that cholesterol lowering in women has never been proven effective(Joel Kauffman, Professor Emeritus of Organic Chemistry, 11 drug patents and 100 peer reviewed publications, Ph.D. MIT). In addition, many Ohio State academic physicians have stated that cholesterol lowering for the vast majority of people is worthless. My brother, Ph.D. Physics and Materials Science at Northwestern said there is not enough evidence to justify the cholesterol theory. In addition, he said that one of the major problems with the Ancel Keyes study is that Keyes only looked at countries that proved his theory and not at the many countries that told an opposite story. For example, France and Switzerland have much higher consumption of fat and their heart attack rates are much lower.

Most heart attacks start with an infection(U. Ravnskov). Yes, my very minor heart attack started when I had a very bad case of pneumonia, my last A1C was 5.4. In addition, I have heard and read too many people complaining about very nasty side-effects of cholesterol medication. I wonder if the people who are telling us to take these drugs would take them themselves? I also wonder if they would enjoy paying the bills? The chance of anyone having a heart attack in any one year, regardless of health condition is 0.2 percent, per year absolute risk(Kauffman). If the medication is going to reduce your risk from 2 in a million to one in one million, why bother?

Finally, the Liptor site admits that the drug does not prevent heart disease or heart attacks. Then, why are we taking the drug, that does not make any sense. Per Kauffman and many professional stats people, if a paper states relative risk, it is worthless. You need absolute risk and all cause morality.

[NDXUFan]

Jerome "The Bus" Bettis, top 5 rusher in NFL history. 5'11" 260. I was 6'2" 250, played sports year round, football, basketball, wrestling, baseball, and track. Was able to run 6 miles per day at the age of 20. Never smoked or drank. How do you explain the fact that I am a diabetic and on dialysis, while these other people smoke all of their lives and never got off the sofa, are not on dialysis? Benched 450 in college.

[Guttercat, ASN, RN]

Never smoked or drank. How do you explain the fact that I am a diabetic and on dialysis, while these other people smoke all of their lives and never got off the sofa, are not on dialysis? Benched 450 in college.

Usually, it's explained by the cold, unfeeling, randomness of one's own genetics. Some people get lung cancer who have never smoked or been exposed to known, airborne carcinogens. Some people smoke all their lives and never get lung cancer--they're merely lucky in that they have genetics that "fight" gene mutations that occur by exposure to cancer causing chemicals.

It's not fair, but genes don't care about fair. Just ask the ESRD patients with Wegener's Granulomatosis or Polycystic Kidney Disease.

I hate kidney disease. Love my kidney patients, but I hate what it does to them. Can't tell you how many times I've walked into the unit, and wished for a magic wand that I could wave over each person. I'd then send them home and tell them never to come back.

[traumaRUs, MSN, APRN]

Guttercat - you rock! You are one awesome nurse....so glad you are a member of AN. You are what's right about nursing!

[Guttercat, ASN, RN]

Guttercate - you rock! You are one awesome nurse....so glad you are a member of AN. You are what's right about nursing!

That's a high compliment.

I'll take it, and thank you so much.

[NDXUFan]

Yes, Guttercat, you are totally correct, I could not agree more with your post. There are a number of IU academic physicians who think it is gene related. You cannot believe how many times I have been blamed for what has happened and most of my weight is muscle mass. If I would have known what would have happened from working that night shift for years, I would have quit, it was not worth it, not ever. By the way, I hate beer and alcohol. My family is from Germany and I hate the taste of beer, like something you would wash your socks in, how awful.

In college, I drank maybe once per year, if that, with a meal. Normally, it was at a wedding and I had to drive home, best friend was visually impaired.