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Protecting patients from themselves...


Specializes in Neuro Critical Care. Has 9 years experience.

I had a patient who had just come back from and angiogram and was on the flat bedrest until 2000. At 2001 she announces to me that she is going down for a cigarette, at which point I suggested that she needed to stay on the floor at least a few more hours so I could monitor her groin site and pulses. Pt stated she didn't want to wait to long since the doors would be locked and stated she would take a wheelchair. I told the patient I would be more than happy to call the MD and get a nicotine patch but that I really didn't feel comfortable having her leave the floor. She refused the patch but did not leave the floor to smoke.

My question is, how far do we have to go to protect patients from themselves? I understand if they are confused or disoriented and I realize smoking is an addiction...but when should their common sense kick-in? Has anyone else had this type of problem or an I just burning out? :confused:

I hate the issue of patient's smoking. It just causes me stress!!!! I am not an crusadaer on this subject either. I do not believe we are going to change the world in a three-day hospital visist. Some doctor's have on their standing orders that they can go out and smoke. Others will not write an order because then they feel they are allowing something they do not believe in. I feel depending on the circumstances that the hospital is not a prison. But, if we let them go and something happens down there, it is my responsibility. We certainly do not have the staff to escort them. We often document the the patient was strongly advised against it, offered a nic patch, blah, blah.... and then do our best to keep them on the floor. It is a losing battle sometimes.

I had a patient who tried to eat a candy bar the day after a partial gastrectomy. He said he had every right to eat what he wanted and to refuse any treatment.

I told him, yes, he did have that right. But with rights come responsibility, and if he ate that candy bar, he would be responsible for the consequences, not me, not the doc, that I would document every bit of our conversation, and the consequences would be very unpleasant if he at the candy. Needless to say, he did not eat it.

I was pleasant, but firm. I told him exactly what could happen if he ate the thing, that we would treat him, but he would be the one to suffer, not us.

I have lost complete patience with patients who want to smoke. I am not a crusader either and was a huge smoker. (I also reluctantly admit I loved smoking and tho there are times when i miss it quitting was one of the greatest acheivments of my life.) However, POST ANGIOGRAM??????? If I was her provider I probably would have told her no and informed her that if she left it would be considered an elopement or leaving AMA and would have made her get readmitted through the ED if she needed to. Do we let alcholics step outside to the bar??

Incidently i was CTS a patient the other nite with chest pain. She was 37 with asthma AND copd. She was still able to go outside to smoke during the day and at home smokes 4 packs/day. Overall I have a hard time even advocating for such patients and treating them. In the end...she just wanted an extra dose of Vicodin (wipe that shocked look off your faces !!)

I feel better served caring for those who recognize that they have to participate in their healthcare to get well.

Now I'm wound i'm for the day....who needs coffee.

In April we become completely smoke-free. No butt huts to go hide in. Pts will be AMA if they insist on leaving to smoke. I dread the backlash, but hey! I am old enough to remember when we quit allowing pts to smoke in their rooms. Plenty got upset, but now it is accepted practice. What a horrible addiction. Slow suicide. I feel for these pts. but I cannot be responsible for their decisions.

Education and documentation is the key. Everyone has the right

to risk, (oriented, of course) I feel it is our job to educate. Cyberkat's statement of telling the patient the conversation would be documented was on the nose!!

bellehill, RN

Specializes in Neuro Critical Care. Has 9 years experience.

Thanks for the comments everyone! I figured it wasn't just my crazy patients who had a complete lack of common sense. Great idea to document entire conversation...I did document that she wanted to leave and how I educated her. Also a great idea to make the hospital smoke-free, I can hear the screaming now!

live4today, RN

Specializes in Community Health Nurse.

bellehill........Thumbs up to you for the excellent job you did with that patient! :)

It kills me when patients are admitted for having had a heart attack, in need of a stress test, and/or cath procedure, and all they wish to do is hurry and get out of that bed so they can travel outside to smoke. :rolleyes: What is it going to take for them to stop killing themselves slowly with nicotine? I'm sure a heart attack aint a picnic! :o

nurseygrrl, LPN

Specializes in HIV/AIDS, Dementia, Psych. Has 12 years experience.

I work in long term care with a young population on my unit. They do many things that I disagree with like smoking, being non-compliant with their diets, being off the floor for hours at a time when they need treatments done, meds given etc. I used to drive myself CRAZY running around after them. Now, I educate them ONCE...then I document like crazy. These people are grown adults. They are going to do what they want so just CYA!!!! :D

I would love to see more specific advice about documenting to CYA. I wish I knew more about my risk of a lawsuit if a pt with a drug abuse hx, who insists on going outside to smoke, is allowed to do so alone, and then found to have overdosed or something. I've had pts who meet the above description, are in private rooms, and not on oxygen - frankly, I'd rather just let them smoke in the room, but I know my coworkers will crucify me. Plus, I'm then basically then giving the pt the message that rules can be broken. I heard a horror story about an OD that ocurred in a similar situation, with the pt's family suing the hospital and nurses, and I don't want to lose my license over this someday.

Honest to God...this just happened at our facility:

we have a pt. with sickle cell. he is extremely dependent on pain med (the doses are deadly to the average human ...65 of demerol q 1hour with morphine pca and booster of dilaudid prn). he is beyond nasty to the staff ( i swear he would surprise the most seasoned nurse) and in my heart of hearts i can't find a single redeemng quality. He is truly an addict and we have lost sympathy for caring about this addiction when he is admitted so that we can continue to give him drugs and he can scream at everyone. Anyhow, last week, his girlfriend brought in cocaine and he injected it in his IV bag. I was in the court of call the cops and get him arrested. The patient actually said 'the nurse put it in his IV bag'. Sadly, he still sits ...i'm sure at present he is on the call light...

As well his dad wrote a letter to the head nurse asking if the 'attending nurse' could help break up Johnny's day by bringing him outside for a 'smoke and some fresh air'. think about that........SMOKE--fresh air...an oxymoron.

Lastly, we have inpatient psych (schizo/bipolar/suicide) and sometimes i feel that these pts should have their smoking privledges (tho the unit smells awful) b/c it's too much for them to be locked up and not be able to smoke. It makes them more crazy.

Tweety, BSN, RN

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac. Has 28 years experience.

I just had to deal with this issue tonight. Patient hounded us and houned us. I go into broken record routine "No smoking on hospital grounds". The nurse whose patient it was (room was very near me so I was dealing with it) called the doc who gave permission. I had to explain to the nurse, the MDs are not allowed to give permission for a patient to smoke.

I just wish the guy would have left and smoked rather than ask. In that case, I just document and let us both have a good night.

In your case, you might have asked her to sign an AMA form to cover you while she's out. I've seen patient do that when they are on monitors.

This is a neverending issue. Just last night I had a 19 year old who was admitted for abdominal pain. She does have Chron's. Anyway she was started on a PCA on admission. Well, her mother called the next day and explained to the doc that her daughter is a drug abuser and she has kicked her out. Her mother actually works at the hospital. Anyway the doctor really gave it to the patient. Dc'd the PCA but we are still giving IV Demerol. There are social serivce issues so she can not be dc'd yet. Anyway she is a clockwatcher and whines all the time. Rates her pain at a 10 no matter what. Last night her friend came and they got all ready to go outside. I was like absolutely not!!! If your pain is still at a 10 and you need this Demerol around the clock there is no way you are going out to smoke. She was so mad!!! I did not care. I am so sick of this. Her friend comes and she is cured!!

We are not smoke free on the premises, (yet) but we do have a smoking policy form they must sign if they have orders to NOT smoke and do so anyways. Also covers removal of risk from us...that we are NOT liable for their noncompliance in any way and are NOT to escort them out of the hospital to smoke.

Someone post angiogram who got OOB and outside against orders... I would be tempted to document as AMA. But if they bleed and come back to the unit, (and I know they do) it's a hassle..... (sigh)Hopefully a nurse has done her/his CYA CYA CYA.

I know doctors and facilities tend to want to hold us responsible for everything but some pts just will not listen. A reason I like critical care is I have standing orders to sedate IV to maintain bedrest post arteriogram PTCA/sheaths, and my docs support it for safety. I also use family to supervise whenever possible.

I admit I tell horror stories to patients and families..of patients needing transfusions and surgical repair of their femoral arteries (risk of death if not caught quickly) to get them to see the seriousness of noncompliance.

I know I would not be patient enough to deal with this smoking issue on the floors so my sympathies are definitely with those of you who do. I would push for policies that protect the nurses from liability, if there are none in place.

Dontcha all hate the noncompliant frequent flyers?? Wish we could keep a list at the ER...and just turn them away...GRRR. Seems a waste of nursing and medical resources sometimes....

One reason why our insurance rates are so blasted high is the treatment and retreatment of irresponsible healthcare consumers. Personally I think THEIR rates should go up, not mine But it just don't work that way, we ALL pay in America. :(

i love when patients on tele want to leave the floor and go smoke....they say "im going to go smoke" and what can you say "i cant stop you from smoking because the hospital isnt prison; but i can tell you that i dont reccomend it and the heart monitor doesnt pick up off the floor so we cant see if something happens" then the doctor writes an order "NO SMOKING" and orders nicotine patch...

i love when the patient takes the patch off and goes downstairs to smoke and comes back and puts the patch back on!!! a r/o MI patient!!

~yanks out all her hair~

Originally posted by mattsmom81

Dontcha all hate the noncompliant frequent flyers?? Wish we could keep a list at the ER...and just turn them away...GRRR. Seems a waste of nursing and medical resources sometimes....

One reason why our insurance rates are so blasted high is the treatment and retreatment of irresponsible healthcare consumers. Personally I think THEIR rates should go up, not mine But it just don't work that way, we ALL pay in America. :(

No kidding. I worked at a clinic where if they had repetitive drug seeking we put a sticker of an airplane on their chart and they were sent a letter saying they had 30 dayss to find another provider. We would often call pharmacy's before giving scripts to find out if they were filling mx. scripts from different providers.

Speaking of a lousy system....how about the fact that your tax dollars are paying prescription junkies to stay out of work on disability when many of them are just sucking up healthcare dollars. To top it off your next patient is a LOL who had an MI or is hyperglycemic b/c she can't afford her meds and she worked her whole life. GRRRRRRRRR

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