Responding to psych patient requests/comments

Published

The other day on a neighboring psych unit, I heard a pt tell his nurse "I lost my dog and I'm going to kill myself if I don't find him! I need you to search for him online!" I wondered what I would have said to him if I was his nurse. Also because I have been preparing for an RN interview, I have been thinking about the question, "Tell of a time when you went above and beyond for a patient."

My thought is that we really need to distinguish between appropriate and inappropriate requests. If we can do that, then it will be much easier to say no to the inappropriate requests, because we are saying yes to something better - keeping the patients safe and helping with appropriate requests.

In my opinion, the pt's request was not reasonable not only because nurses don't have time to do that, but because he is taking no responsibility for his own life, he's putting it all on his nurse. I thought about a response like "Have you considered calling a friend or family member to do the search for you?" Then I thought about what I would answer if the person said "I have no friends." I thought about saying "How did that happen?" but that didn't seem optimal. So I thought I would call on you trusty psych nurses, like Davey Do, to give me your thoughts on these type of situations. What are some good things to say to people who don't take responsibility for themselves? Also, any tips you have for responding to typical requests/comments would be helpful.

I had one situation recently when my response seemed to work. The pt stayed back from lunch, then asked to be taken to the cafeteria. We were lacking staff to do so, so I told him that I would try to find someone. He said "It seems like you don't care." I responded "It may seem that way, but that's not really how it is."

Up Vote Up Vote ×
The other day on a neighboring psych unit, I heard a pt tell his nurse "I lost my dog and I'm going to kill myself if I don't find him! I need you to search for him online!" I wondered what I would have said to him if I was his nurse. Also because I have been preparing for an RN interview, I have been thinking about the question, "Tell of a time when you went above and beyond for a patient."

My thought is that we really need to distinguish between appropriate and inappropriate requests. If we can do that, then it will be much easier to say no to the inappropriate requests, because we are saying yes to something better - keeping the patients safe and helping with appropriate requests.

In my opinion, the pt's request was not reasonable not only because nurses don't have time to do that, but because he is taking no responsibility for his own life, he's putting it all on his nurse. I thought about a response like "Have you considered calling a friend or family member to do the search for you?" Then I thought about what I would answer if the person said "I have no friends." I thought about saying "How did that happen?" but that didn't seem optimal. So I thought I would call on you trusty psych nurses, like Davey Do, to give me your thoughts on these type of situations. What are some good things to say to people who don't take responsibility for themselves? Also, any tips you have for responding to typical requests/comments would be helpful.

I had one situation recently when my response seemed to work. The pt stayed back from lunch, then asked to be taken to the cafeteria. We were lacking staff to do so, so I told him that I would try to find someone. He said "It seems like you don't care." I responded "It may seem that way, but that's not really how it is."

Well, I'd probably make a quick judgement as to the validity of the "lost dog" story. In 99.9% of cases, I'd probably decide that there's no truth to it, but if the patient believed it, I would encourage them to talk about it and attempt to develop a rapport. Letting them talk usually eases their anxiety a bit and shows concern.

The threat of suicide must also be evaluated. Do they have a plan? Do they have a way to carry out the plan?

What I did beyond that would depend entirely on the patient. Are they jumping from delusion to delusion and likely to forget all about this "dog"? If so, I might tell them that I'll try to look as soon as I have time.

Are they agreeable to PRN medication that usually helps? I might suggest that.

They say "reorient to reality", but in my experience that rarely helps and can even agitate the person further. Some people are delusional at their baseline and just need help coping with the anxiety their delusional thoughts provoke. They won't ever get "well".

***If their dog really was lost, I'd probably help look for it.

Up Vote Up Vote ×

Thanks, Sour Lemon, I really appreciate your feedback. One thing didn't describe about this situation was that the patient was alert, oriented, and did not even appear upset (it is hard to convey tone of voice and body language online). So when he said "I'm going to commit suicide if I don't find my dog" it did not strike me as credible at all. Instead, he came across as demanding. Contrast that with another patient a few years ago who tried to AWOL because he was worried about his dog that was alone in his apartment with no one to care for him. That patient was genuinely distraught, and in that case the social worker contacted his clinical team and made sure that his dog was taken care of. Because of the demeanor of the patient with the "lost dog" my judgment was that either 1) He was making it up, or 2) He might really have an issue, but since he didn't seem upset, I thought it would be better to help him find his own solution by contacting family/friends, like the saying "give a man a fish you feed him for one day, teach him to fish you feed him for a lifetime."

I am reminded of another incident that happened a few years ago when a patient told me that he needed to be discharged because his infant daughter was in the ICU. When I informed the psychiatrist, he told me to call the children's hospital and ask if they had any infants with the name the patient had given me. When I did so, the hospital said they had no infants with that name. When I told the patient this, he said "It's harder to get out of this hospital than I thought". So maybe the bigger issue is distinguishing between truth and fiction. How would you verify the "lost dog" story?

Up Vote Up Vote ×
Specializes in Hospice, corrections, psychiatry, rehab, LTC.

My take on it the way that it was presented to you was that it was a clear attempt at manipulation. Your clarification that there was no apparent distress in the patient and that his tone was demanding further reinforces that.

Reminds me of a former patient who called the unit to ask if she was going to die from taking a bunch of dog vitamins. She seemed disappointed when I told her, "You're probably going to be nauseated for a while, but that's about it." I believe that she was wanting for me to tell her to rush to ER. She definitely got secondary gain from having people fuss over her.

Up Vote Up Vote ×
My take on it the way that it was presented to you was that it was a clear attempt at manipulation.

Yes, Orca, I agree that it appeared to be a clear attempt at manipulation, which I can understand was not evident in my original post which was why I clarified it. I'm wondering if there is a better response to these types of requests.

If a pt says to me "But nurse x lets me do y!" I have learned to say "It doesn't matter what nurse x does, I am your nurse today, and this is the way we're going to do it" which generally works well in shutting down the staff-splitting. But in the case of the "lost dog" story, I was wondering what I would have said. I'm not sure "I don't believe you" is appropriate even thought that's what I'm thinking.

Up Vote Up Vote ×
Specializes in Psych, Addictions, SOL (Student of Life).
The other day on a neighboring psych unit, I heard a pt tell his nurse "I lost my dog and I'm going to kill myself if I don't find him! I need you to search for him online!" I wondered what I would have said to him if I was his nurse. Also because I have been preparing for an RN interview, I have been thinking about the question, "Tell of a time when you went above and beyond for a patient."

My thought is that we really need to distinguish between appropriate and inappropriate requests. If we can do that, then it will be much easier to say no to the inappropriate requests, because we are saying yes to something better - keeping the patients safe and helping with appropriate requests.

In my opinion, the pt's request was not reasonable not only because nurses don't have time to do that, but because he is taking no responsibility for his own life, he's putting it all on his nurse. I thought about a response like "Have you considered calling a friend or family member to do the search for you?" Then I thought about what I would answer if the person said "I have no friends." I thought about saying "How did that happen?" but that didn't seem optimal. So I thought I would call on you trusty psych nurses, like Davey Do, to give me your thoughts on these type of situations. What are some good things to say to people who don't take responsibility for themselves? Also, any tips you have for responding to typical requests/comments would be helpful.

I had one situation recently when my response seemed to work. The pt stayed back from lunch, then asked to be taken to the cafeteria. We were lacking staff to do so, so I told him that I would try to find someone. He said "It seems like you don't care." I responded "It may seem that way, but that's not really how it is."

At our free standing psych facility we actually house the dogs of our homeless patients. If they have no one to care for them. Our boss even went and got one out of the pound that would have been euthanized before the patient could have been discharged.

The thing with psych patients is their disease process often prevents them from being able to take responsibility for themselves and they often literally have no one they would consider a friend. Often their dog is their only friend in the world. The large majority of psych patients don't choose to be sick anymore than cancer patients do. While I agree that a nurse would not have time to do an on-line search I find your proposed answers to be unnecessarily unkind.

I always try to answer these types of questions by first putting myself in the perspective of the patient. How would I feel if my dog was lost and I could not go look for it. Also I would have to assess the patient's reality testing to even know if there was a dog in the first place. If a patient is that worried they become a high awol risk. I actively engage a patient to help them identify solutions for lots of everyday problems that we normies find routine.

As psych patient cannot focus on getting well if they are burdened by excessive worries. In my opinion you have to have a lot of empathy to work effectly with psych patients. It's really something you can't learn.

In the case of the cafeteria guy did you actually see if you could find someone to take him to the cafeteria, or did you just blow him off with the comment. I would have had a security guard or someone from the from the admin building come down and walk him over if necessary. You know just because they are mentally ill doesn't mean they're stupid. They need to trust you. My nurse to patient ratio today was 16 to one with two aids and an LVN passing meds, but I am nver too busy to show kindness to my patients.

Hppy

1
Up Vote Up Vote ×

It's very difficult to tell over the internet. I have spent time after I finished my charting pouring over the internet for appropriate rehab facilities for patients and finding the best coloring pages or phone numbers or whatever they need- but it depends on the patient's condition. Assuming based on the above comments that the patient is being manipulative or has a history of manipulative behavior, I may respond by saying "I'm in the middle of a task right now, but I can get you the phone numbers for local animal shelters in just a few moments. Why don't you have a seat here near me and while I finish this up". At that point, the patient is within my visual range (safety) and I can assess their demeanor and behavior for a few moments. They are not successful in demanding what they want when they want it, but are provided a solution to help locate their dog. Delusional patients entirely change the situation, of course.

Up Vote Up Vote ×
Specializes in Psych (25 years), Medical (15 years).

Thanks for the plug, Elizabeth!

The other day on a neighboring psych unit, I heard a pt tell his nurse "I lost my dog and I'm going to kill myself if I don't find him!

I guess my response would be, "But what if you follow through with your threat and and we find the dog after you do yourself in? That would be a real bummer!"

Just kidding.

Most people just want to be heard and their feelings validated, so that's what I'd do first- you know- "I understand you're worried about your dog, that's an appropriate way to feel, etc. Then I would do what I appropriately could as far as helping the patient find the dog, like elicit help from whoever.

I have gone as far as rescuing a psych client in the community's cat on one occasion.

Bottom line, the patient's safety comes first. After validating his feelings, assuring actions would be taken to find his dog, I would have the patient commit to safety or deal with the ramifications of his threat, e.g. inform him he will be put on a 1:1 status to assure his safety.

99.9% of the time, patients who are not high maintenance or axis II will commit to safety rather than have a staff member watch them while they potty.

Up Vote Up Vote ×
Specializes in Varied.

There are many contextual elements to this story you cannot answer to that make this a difficult post to respond to. As far as I can read, you may need to seek better ways to phrase what you're saying. As I have said before, context always matters, and a bunch of strangers on the internet aren't going to have all the answers. Maybe ask peers? People who are witness to what is occurring and can provide timely feedback, without missing contextual elements.

Instead of saying:

"It may seem that way, but that's not really how it is."

Instead say: "I am sorry you feel that way and I will identify someone who can assist you as soon as possible. I cannot take you in this moment, but if you give me x amount of time, I may be able to look for someone."

How are you going to solve the problem? (The problem being his feelings of neglect.) You didn't do much, in your recall of your scenario, to fix the issue.

Up Vote Up Vote ×
Specializes in Psych, Addictions, SOL (Student of Life).
I would have the patient commit to safety or deal with the ramifications of his threat, e.g. inform him he will be put on a 1:1 status to assure his safety.

Wow - you ahve a lot of power - in my facility it practically takes an act of congress to get 1:1 supervision on a person who is verbalizing without otherwise acting out.

I'm impressed - maybe I should look into Wrongway?

Hppy

Up Vote Up Vote ×
Specializes in Adult Primary Care.

I'm not in Psych, but I am a sucker for animals!! Several years ago I sent a patient from my office to the ER who was having a stroke. She did not want to go because she had a cat at home. I took her house keys and took care of her cat for several days until her family could come and get the cat. (I was her Primary for several years and she knew me very well).

Up Vote Up Vote ×

I work in Psych and I have dealt with a lot of these requests. First, in that situation, the patient will need to be reoriented. Its likely he doesnt know where he is, if he is saying his dog is lost. That means he likely has absolutely no idea what is going on. I would go over all of that with him. Answer any questions he has. Offer to allow him to call a family member for extra support and confirmation of the situation. Then, I would try to redirect him to a different task or form of entertainment. Patients often lose their grip on reality. We have to bring them back to it. Usually, through medication changes, they keep that grip in time. But until then, "Lost dogs" will keep happening. Lol

Hope this helped!

Up Vote Up Vote ×
+ Join the Discussion