Patient refuses discharge what to do? long...

[chapsticknurse]

Hello! We had a patient once that was just a bit difficult to handle. She wanted all care done on her schedule. She would actually put notes on her door stating, " Do not come in or wake me up until noon". She was supposed to get some non-invasive diagnostic tests done (ultrasound etc) however would always state "later, when I get more pain medication" Later became two days later! She would refuse an xray because she was in too much pain to sit still long enough.

She also kept leaving the facility all together to go smoke. She was not steady on her feet however did not listen to anyone's advice. Nicotine patches were offered, managers talked to her, doctors. However her pain was always 10/10.

Finally the MD's got together and stated that if she didn't want any diagnostic tests done then she would be discharged. She still refused diagnostic tests and kept asking for pain medication. Very strong opioids were gived around the clock plus continuous dosages. She kept maxing out on the recommended dose before time was up. No MD would give her more meds especially since she was refusing all other care. (refused fingersticks, vital signs etc) She kept kicking people out of her room.

So she was discharged in the early morning. However would not leave. She kept threatening to sue us and kept calling her lawyer. Our managers went to the MD's, house supervisors and the facilities legal team. What happened was that she would just stay in the room but no care would be given until she just left.

I'm just wondering what your thoughts are on this whole situation. I mean what the heck are we supposed to do, just let her refuse all care but keep giving her pain medication that jeopardizes her safety?

[kimmie4476, ASN, RN]

At our hospital, if a patient goes outside to smoke after being told not to, we can potentially consider it leaving AMA and tell the patient as such. For instance, I will tell the pt., "you are not a prisoner here, however, if you leave to go outside to smoke it will be considered leaving AMA as we are a smoke free facility which means you have to go across the street. You are welcome to come back for treatment, but you will have to be processed through the ER and may or may not be readmitted. (of course I usually talk to the MD first before threatening them with this) " It sounds harsh, but sometimes it's what you have to do.

[elkpark]

I was involved in a few situations like this when I worked on a psych consultation-liaison team in a large teaching hospital a number of years ago. Your organization is running a hospital, not a Holiday Inn, and this client can't just choose to live at the hospital. If it is the opinion of the physicians involved that she is medically stable and no longer requires acute inpatient care, and she is refusing the treatment being offered (diagnostic tests), she can be discharged whether she wants to go or not, and security can escort her from the property if she refuses to leave voluntarily (that was the advice from the hospital's legal department). This is usually referred to as an "admininstrative discharge."

[ImThatGuy, BSN, RN]

It was sunny and 77 degrees out. As a staff member of any organization, at least here, you have the right to tell someone to leave. If that someone refuses they're then remaining on the premises without license to do so. That means they're trespassing. That's where I come in. My name's Friday. I carry a badge.

Point to the door and call security, police, or whoever. Sometimes it's just a little bit harder to take out the trash.

[classicdame, MSN, EdD]

Even if the patient is allowed to stay without care you are still responsible for them in so many ways, such as falls. Why risk a lawsuit? If she has no medical reason to stay then call security.

[mamiekay]

The patient was "just a bit difficult to handle"?!?! She was in a hospital, not a hotel! When I have patients like that, first I explain to them that the hospital treats hundreds of people every day and we may not be able to accommodate their own personal schedule preferences. Then I write a note in their chart--"Pt was scheduled for xyz, she refused." It's a small hassle, but if you chart every time the patient refused vitals, gluc checks, ADL's, treatments, tests or any other kind of care, she'll have no lawsuit when she's escorted from the property by security. The MD's certainly should have d/c'd her pain meds, and told her why, when she refused all treatments. "I'm sorry Ms. Patient, if you refuse to allow us to run the necessary diagnostics to properly care for you, I can no longer, in good conscience, continue to give you pain medications. It's simply not safe." That might have encouraged her to leave voluntarily. The bottom line is document, document, document!!!

[KY RN]

You want IV pain meds, you don't go off the floor. If you go off the floor, you will not get IV pain meds because we cannot assure your safety. If you refuse to leave, we have HUGE security guards that will escort you out.