Question for Psych RN's about pt on cardiac unit

morte, LPN, LVN · Aug 25, 2007

Hi there!. He is not competent to make medical decisions for himself right now. The thing is that we have had several people visit him from a church he used to attend who have all said that he is a very kind, intelligent, musically gifted man when he is taking his psych meds. Hard to compare with the man who spits, tries to bite, and who makes sexually explicit overtures to the staff! One of our MD's who rounded on him today tried to get the ball rolling to get him TDO to a psych facility to get him the help he so desperately needs. The case mgr also got involved. They made numerous calls to the community mental health services board, and finally got some guy to come out and "see" him (he wasn't even a licensed health professional). His report basically said that they would call the psych facilities in the area, but doubts that any would accept him. Oh, did I mention that we had our in hospital psychiatrist do a consult/eval two weeks ago, and have not seen him since? As a medical hospital we are not equipped to deal with pts who are as psychotic as he is. There is nothing medically wrong with him, but the psych hospitals are using his medical history as an excuse to deny admitting him. The sad thing is that I feel certain that if he could get into a good psych hospital he has potential to get better. Even the VA hospital who was treating his mental health issues denied him on the basis that he has to agree to sign himself in. What happens now? Do we keep this poor man until his insurance runs out and turn him loose on the street, with the potential for self or other violence? We can't keep him forever. How do we get him help? Even though he scares me, I still feel sad that he really needs help, and is not getting it.
Have any of you had similar experiences? What are his options? FYI, I am in Virginia, if anyone has experience with how this works here it would be appreciated.
Amy

if the VA is treating, he must be a vet?...i cant see how they could refuse to take him....has he been declared LEGALLY incompetent?

try (or have SS try) calling the VA to clarify...also try your Congressman/woman.....good luck

NurseHotFlash · Aug 28, 2007

My son has schizophrenia, and I know how impossible it can be to get a psych patient help. Is there anyway you could get someone to prescribe a psychotropic med for him? When my son gets "out there" sometimes he comes around with minimal meds and then you have a chance of working with him. When he does become rational, try to use only "if, then" requests. i.e. "If you cooperate, then we can consider letting you can leave." or "If you continue to fight our efforts, then you will have to stay here". There isn't much point in trying to convince them you are not poisioning their food, or that any other delusion isn't real. Good luck with him, and thanks for caring so much!

NurseHotFlash · Aug 28, 2007

Forgot to tell you, I am in Florida. Here a psych patient can be held against their will for 3 days for evaluation, and longer if deemed to be a danger to self or others. During those three days, my son was often forced to take meds. Forcing the meds was the only way to help him.

IMustBeCrazy · Aug 28, 2007

Here's the dilemma.

From what I read, no where in your info did you state that this pt is involuntary. If he is not being detained, how can your unit legally justify keeping him in the hospital against his will??

On the other side of the coin, since he is so sick, your hospital needs to consider how safe he is to others as well as himself. If he is so sick that he continues to physically threaten staff at this point, that boy needs to be lawfully detained (this is one for your hospital Ethics Board stat), then EMTALA can take over and you can get him transferred out of your unit and to a more appropriate placement to a psych facility that accepts legally detained patients. Per EMTALA, this pt can not be turned away from a psych hospital, they are mandated to take him if they have a room available.

Good luck!

al7139, ASN, RN · Aug 28, 2007

Thanks for your replies,

This is such a hard situation for me, as I am a new nurse, with little experience. Here in Virginia, the psych hospitals can reject admitting this man on the grounds that he has other medical issues (even our larger sister hospital with medical as well as psych has denied him). They are using his MI as an excuse not to take him. We have had two of our hospitalist MD's and the case nurses trying so very hard to get him placed somewhere to no avail.

We have psychotropic meds ordered for him, but he refuses to take them, and they are not available in IV/IM form (Lithium, Zyprexa, etc.). We have Haldol and Ativan ordered for him also, but I have not seen that they make much difference since they do not specifically treat his disorder. The last time I worked with him (Friday evening), I got the feeling that he was aware of where he was, and what was happening, but chose to continue his behavior in order to continue to get our attention. I was taught in school that lots of people with psych problems are very intelligent, and manipulative. The reason I say this is that the MD ordered his CVL removed, and I was very concerned about his understanding about the procedure for removal of a CVL, and having to be in such close proximity to him for a period of time (direct pressure after removal), and him not fighting it. We gave him IV haldol, and IM ativan before the procedure, and restrained his legs so he could not kick while I removed the CVL. I also had our hospital security standing by outside the room (out of sight) just in case. Me another RN, and an aide went in to start the procedure, and he was quite well behaved for the entire time. I explained what I was going to do, and he was quite content to lie there and let me, since he had people paying attention to him. It is when we are not there, and not giving him our undivided attention that he starts to behave inappropriately and aggressively. This is what makes me think that he is well aware of his actions and is manipulating us. When I have him as a pt, he will initially say when I ask that he would like to start taking his meds so he will get discharged, then when I bring them will refuse them and not talk to me (this happens with all the RN's who have worked with him). He will not eat anything because initially we did try to give his meds with food.

How do you work with a patient like this? He understands that if he would take his meds, he can leave. He still refuses. No psych hospital will take him based on his recent medical problems.

My most important question is this: How do I, as a unit RN with very little experience and no authority get this guy the help he needs? What is the proper chain of command? Is it the same as it usually is? Charge nurse to ClinII to Unit Manager to etc? Or can I notify the Ethics Board and Pt Advocacy of the situation? He really needs someone to act on his behalf whether its the state or whatever, because what is happening right now is getting to the point of being inhumane, since noone can seem to decide how to handle this situation.

Amy

rn/writer, RN · Aug 28, 2007

If this man is not competent to make decisions about his own care and is showing the potential to harm himself, it sounds like you might do well to contact the hospital social worker to see about getting a guardian at litem for him. This may be an impossible dream if you have a bunch of people all eager to pass the buck, but it might be worth a try.

Best case for someone with severe psych issues is for them to appoint someone they trust (when they are lucid) to make decisions for them when they are having a crisis. During a period when they are "in their right mind," they can make provision for those times when they are not. Unfortunately, once they are in a psychotic state, the process becomes much more difficult.

Let us know what happens.

purplekath · Aug 28, 2007

Hi Amy,

Tricky situation for you! I'm in Australia and have no idea how the system works over there. With regard to managing this guy on the ward, you need to know that he is not doing what he's doing deliberately or to be manipulative. He is manic. This means he only has limited ability to control his behaviour.

His thoughts are running very fast and loud in his mind right now, so you need to keep things clear and firm. If possible, have the same nurses looking after him from shift to shift. Gather your meds in oral and IM/IV form where possible. Zyprexa comes in IM form. Grab hospital security and several other nurses/orderlies...whatever. You shouldn't have to restrain him..just a show of presence will usually work. I'm assuming at this point, he is under some kind of treatment order and can be "forced" to take his meds. If not, this should be organised before you proceed.

Approach him confidently, offer him the choice of taking his medication orally. At the first refusal, be firm, give him his medication IM, then retreat. After a few minutes, go and reassure him that while he doesn't see it now, he is unwell and needs medication to get well again. Remind him that he has been unwell before and that he is a wonderful man who doesn't behave this way when he is well.

Anti-psych meds can take a few weeks to work for some, but they are quite sedating. You might also want to get him written up for something like Diazepam or Clonazepam, which can both be given IM. These will slow him down a little while the other meds work. Sleeping medication for night is a very good idea as he will have missed a lot of sleep while in this manic phase. As he begins to settle, he will then be more willing to take the Lithium, which is what he really needs to get well.

Sexually inappropriate or aggressive behaviour you must be really firm about. Be clear and firm, "No (name)! This is not acceptable". Don't be afraid to call security.

The other crappy manic behaviour like pulling out IV lines etc you just have to manage by the seat of your pants, using the principle of positve/negative reinforcements eg: - re-cannulate/re-tube him every time you need to if you have to...he will soon get tired of that program I can assure you! Figure out what he likes, and have it on hand as a kind of "reward" when things are going well...I know it sounds bad, but sometimes it works and when it comes to psych, there is no "right way". I have a particular very aggressive patient who LOVES gummi bears...the minute I hear he has been admitted, I buy some, and let me tell you...those little squisy bears have defused many a "situation" before it starts.

Best of luck Amy - and keep us posted on what ends up happening with this poor guy.

TrudyRN · Aug 30, 2007

Hi there!
I am a nurse on a cardiac unit. Although most pts we see are "normal" or at least taking meds for their psych issues, we occasionally get some really tough pts to work with.
We have a man on our unit right now who arrested due to an MI, and was resuscitated and had a cardiac cath to open a blocked coronary atrery. The problem is that this pt has a long history of bipolar disorder and is very paranoid. According to his H&P, he was combative in the ED, and ever since he has been in the hospital has been in restraints (2 point wrist), because he has the potential to be violent, and pulls out foley, NG etc. The issue we are dealing with now is that at this point there is nothing that requires him to stay here on our unit, except that he refuses to take his meds, eat (he thinks we are drugging his food), and we cannot trust him not to hurt himself or others. His family is just as sick as he is mentally, and want nothing to do with him. He is not competent to make medical decisions for himself right now. The thing is that we have had several people visit him from a church he used to attend who have all said that he is a very kind, intelligent, musically gifted man when he is taking his psych meds. Hard to compare with the man who spits, tries to bite, and who makes sexually explicit overtures to the staff! One of our MD's who rounded on him today tried to get the ball rolling to get him TDO to a psych facility to get him the help he so desperately needs. The case mgr also got involved. They made numerous calls to the community mental health services board, and finally got some guy to come out and "see" him (he wasn't even a licensed health professional). His report basically said that they would call the psych facilities in the area, but doubts that any would accept him. Oh, did I mention that we had our in hospital psychiatrist do a consult/eval two weeks ago, and have not seen him since? As a medical hospital we are not equipped to deal with pts who are as psychotic as he is. There is nothing medically wrong with him, but the psych hospitals are using his medical history as an excuse to deny admitting him. The sad thing is that I feel certain that if he could get into a good psych hospital he has potential to get better. Even the VA hospital who was treating his mental health issues denied him on the basis that he has to agree to sign himself in. What happens now? Do we keep this poor man until his insurance runs out and turn him loose on the street, with the potential for self or other violence? We can't keep him forever. How do we get him help? Even though he scares me, I still feel sad that he really needs help, and is not getting it.
Have any of you had similar experiences? What are his options? FYI, I am in Virginia, if anyone has experience with how this works here it would be appreciated.
Amy

I think the VA is messing with you. Have they never heard of involuntary admission? Maybe you can get him to a state mental hospital, where they likely have to evaluate him. Or get him to the VA facility if he is a vet and let them evaluate him whether they want to or not. What a flippin' mess. It is criminal how we treat sick people in this great nation.

BTW, get another psychiatrist to eval him and report to the licensing board the sluggard who hasn't gotten back to you in 2 weeks.

What higher-up's have you gone to and what has each one said? Isn't there a social worker involved? What about your DON and/or your Chief of Psychiatry and/or Chief of Medical Staff? Is he insured? If not, I'd think your billing folks would be all over the doc to discharge him, at which time he can be taken by ambulance to VA for eval.

If all else fails, maybe the TV, radio, and newspaper people should be made aware anonymously.