Pt refusals

Altra, BSN, RN · Mar 20, 2012

I recently observed an ortho surgeon comment to a patient, "It's unfortunate, but every once in a while a patient of mine doesn't do well ... not able to tolerate the standard things we do to minimize complications, not able to take small incremental steps towards their own recovery. These people end up in nursing homes because they're unable to care for themselves." (sigh, shake of head while walking away)

What a miraculous turnaround in that patient's participation in his own plan of care!

LynnLRN · Mar 20, 2012

I had a pt like this once and he developed all the complications (blood clots, pneumonia, ileus- ended up with NG tube). I thought it was hard to get him up and moving prior to the complications, but once he got the complications he was even more resistant. Some people are just so irrational it is very hard to deal with.... he went home and died.

I hate when it is the patient who does everything right and ends up with complications, makes me feel so bad for them.

Cuddleswithpuddles · Mar 20, 2012

For the seasoned nurses....

Was there a time when most patients were less likely to go against doctors' orders? It seems like the anthem nowadays is me-me-me-my-choice-customer-is-always-right, please the patient to get Press Ganey scores up etc. etc.

I am wondering if there was less of that mentality back then when it came to refusal of the plan of care.

Thanks.

nguyency77, CNA · Mar 21, 2012

For the seasoned nurses....
Was there a time when most patients were less likely to go against doctors' orders? It seems like the anthem nowadays is me-me-me-my-choice-customer-is-always-right, please the patient to get Press Ganey scores up etc. etc.
I am wondering if there was less of that mentality back then when it came to refusal of the plan of care.
Thanks.

I've been wondering the same thing. Why is it that suddenly every magazine has at least one headline saying, "SHE FOUGHT HER DOCTORS... AND WON"? Why is our healthcare turning into a system where patients believe they know better than their physician or APN, who has spent a large number of years out of their life in medical school?

I used to be an intern for this obgyn, and it seemed like every other day we would have some hysterical patient come in with a thousand print-outs from WebMD of possible but irrelevant diagnoses. Not that I advocate paternalism, but I'm really not for this "I cannot figure out the meaning behind the top and bottom numbers of my blood pressure but I will nonetheless freak out because I think 100 of anything is high, and the doctor doesn't know what he's talking about."

applewhitern, BSN, RN · Mar 21, 2012

Altra, I wish nurses could say stuff like that. If I said that to a patient at my facility, I would be fired.

mindlor · Mar 21, 2012

Nursing school 101 right? The patient ALWAYS has the right of refusal. We smile and document.

Remember autonomy?

GitanoRN, BSN, MSN, RN · Mar 21, 2012

we can't obligate anyone to do anything therefore, we can only educate the pt.

Vespertinas · Mar 21, 2012

For those who are only moderately difficult, what I find works is flexibility. If they want to refuse PT, I tell them they must go today but if now is not a good time, please tell me when would be better for you. That way they still feel like they accomplished their mission of exercising their independence but I got them to go to PT by the end of my shift.

For those who flat out refuse everything, I have started to get cocky enough to ask them whether we should discharge them now because it seems there is nothing more we can do for them. Sometimes they may even benefit from a psych visit.. perhaps they're too depressed to participate in their own care.

Merlyn · Mar 21, 2012

So I had this post-op pt who absolutely refused to do anything. No ambulating, convinced the PA to let them keep their foley. All the while screaming "I know my own body!!"
I told them in gory detail all of the complications of refusing to move at all, I cajoled, I demanded, I sent comrades in arms. The pt absolutely refused to budge an inch. I finally convinced them to at least wear their teds and SCDs and to use their inspirex. I gave the heparin and made them move to one side or the other every other hour. Ibasically did everything in my power to prevent all of those complications.
How much do you want to bet that the pt will go home complication free and say "I told them so!"

We only study medicine for god knows how many years. They watch General Hospital every day. They know that all that the Nurses and Doctors do is divorce one another and hop into the sack with lawyers. They are well informed.

mindlor · Mar 21, 2012

I am not sure why all the worry. Teach them, if they refuse, document. If they die, shame on them. Move to next patient.

wooh, BSN, RN · Mar 21, 2012

every other day we would have some hysterical patient come in with a thousand print-outs from WebMD of possible but irrelevant diagnoses.

We had a Trisomy 21 kid going into CHF, the mom refused to give a dose of lasix until she researched, then once she was done she comes and refuses to give the lasix until we got a Magnesium level. Apparently lasix can lead to low Magnesium in a Downs kid. I wanted to tell her that's nice, but CHF will KILL your child before that Magnesium level gets back if you don't let me give the beaver dam lasix!! (And ironically, she didn't care anything about the potassium level.)