The psych patient on a tele unit

[Johnny Moo Man]

Had a few of the weird ones on the same hallway yesterday but by far the most time consuming was the 22 year old who demanded her husband spend the night. At first I thought sure, as long as it's okay with the night nurse, if it'll make you feel better it's okay. She started talking about how mean the nurses on the other floor were last visit and how she went AMA. Okay so we called the other floor, apparently at night the husband goes into other patient's rooms asking for money. So, no, he can't stay, and the director put her foot down. So out comes the psych. "I have nightmares and multiple personalities, ooh, here comes another personality right now, what are you F*ing going to do when I start hitting nurses? You better have a document to restrain me from my husband, he's my legal guardian!!"

And of course her husband, who has been sitting there picking scabs from his arms, chimes in with the threats of how he's going to "sue this hospital." Then comes the usual from the patient: " I WILL go AMA."

So my questions: How do you actually deal with these psych patients? Of course you can't give in to their demands, but how to be diplomatic? And why can't we say, "go ahead and sue, take on our corporate lawyer with your imagined disrespect," or "Please do go AMA because I'm sick of you already." And why is this AMA such a big threat with the people you really, really want to go AMA, do they think we need them?

Maybe I have several questions. But I'm perplexed by psych, they make the job tedious and the day long, the same people keep needing the nurse in there constantly and are always asking to speak to the charge.

As always, thanks in advance.

[merellis2009]

I also work on a tele unit and our hospital doesnt have a psych floor so essentially psych patients are everywhere.

1. I document, document, document.

2. Just give the charge nurse a heads up on the situation so that if you need more time to deal with this patient and document everything, she'll know why.

3. If needed, get the charge nurse involved.

4. Stay calm. If they're unhappy with the quality of services received ask them for specifics. Address each specific problem by citing hospital policy and protocol.

5. If your hospital has a care line phone number to call when patients are dissatisfied, then tell them to call.

6. Remind them that they are there by their own choices. No one is forcing them to stay anywhere. They may sign out AMA if they choose but insurance may or may not cover their charges due to AMA status

Good luck!!!

[Altra, BSN, RN]

So out comes the psych. "I have nightmares and multiple personalities, ooh, here comes another personality right now, what are you F*ing going to do when I start hitting nurses? You better have a document to restrain me from my husband, he's my legal guardian!!"

And of course her husband, who has been sitting there picking scabs from his arms, chimes in with the threats of how he's going to "sue this hospital." Then comes the usual from the patient: " I WILL go AMA."

So my questions: How do you actually deal with these psych patients? Of course you can't give in to their demands, but how to be diplomatic? And why can't we say, "go ahead and sue, take on our corporate lawyer with your imagined disrespect," or "Please do go AMA because I'm sick of you already." And why is this AMA such a big threat with the people you really, really want to go AMA, do they think we need them?

What you are describing here is not acute psychosis but well-learned, long-standing patterns of manipulation from an alert & oriented patient. This patient's hx may include one or more psych dx, but you will see equally manipulative behavior from patients/families with no psych hx too.

Reiterate to the patient & her husband:

1. Husband is not permitted to stay overnight d/t behavior on previous overnight stays. Make sure you have back up from your charge nurse.

2. Pts. are not permitted to verbally or physically abuse staff in the hospital any more than they are outside the hospital. If this occurs, appropriate action will be taken, including restraints if deemed necessary. No "permission" from any legal guardian is required if patient is actively harming him/herself or others.

3. All patients always have option to sign out AMA. Pt. has been admitted to the hospital with X diagnosis and is encouraged to stay to receive care. Risks of signing out AMA include X,Y, and Z.

At this point I would ask if pt. or her husband had any questions, then state that I will give them some time to reflect on the information I have provided and will return in 30 minutes to see if she plans to stay or if I need to initiate AMA paperwork.

[elkpark]

Just to complicate the situation further :), if it's true that her husband is her legal guardian (not saying I believe that, because, obviously, neither of them is a reliable source of info -- but you need to get that sorted out because it matters a lot), then she can't sign herself out AMA, because she has no legal right to give or withhold consent for treatment. That would be her husband's decision ...

[madwife2002, BSN, RN]

Pt is obviously sane enough to know about AMA so give them the paperwork and say bye bye.

[Altra, BSN, RN]

Just to complicate the situation further :), if it's true that her husband is her legal guardian (not saying I believe that, because, obviously, neither of them is a reliable source of info -- but you need to get that sorted out because it matters a lot), then she can't sign herself out AMA, because she has no legal right to give or withhold consent for treatment. That would be her husband's decision ...

Good point.

[elkpark]

Pt is obviously sane enough to know about AMA so give them the paperwork and say bye bye.

It's not a matter of the nurse's (or anyone else's) opinion about the client's state of mind, it's a legal question -- if she has been ruled incompetent and a guardian appointed by a judge, she no longer has the ability, legally, to give or withhold consent for treatment of any kind. Her signature on an AMA form (or initial consent/admission form, for that matter! :uhoh21:) would have no more validity than my dog's signature would ...

[EarthChild1130]

As another poster said, this is NOT an acute episode...merely a person who is trying to manipulate a situation using coping skills which she has found to be effective. My advice would be to 1) Document EVERYTHING 2) Set firm boundaries and limits, and be willing to enforce them if/when she pushes the issue, up to and including restraints if she gets physical 3) Maybe ask for papers proving that hubby is indeed the legal guardian? Other than that, if they can't prove it I would likely get the charge nurse/nursing supervisor involved on that point...I work psych and those patients drive ME nuts!

[Balder_LPN, LPN]

It's not a matter of the nurse's (or anyone else's) opinion about the client's state of mind, it's a legal question -- if she has been ruled incompetent and a guardian appointed by a judge, she no longer has the ability, legally, to give or withhold consent for treatment of any kind. Her signature on an AMA form (or initial consent/admission form, for that matter! :uhoh21:) would have no more validity than my dog's signature would ...

About AMA forms, aren't they more to protect the provider from liability than anything else. I mean you can't MAKE someone sign it. Before I was a nurse I AMA'd out of an ER, no sign no nohting

[Altra, BSN, RN]

About AMA forms, aren't they more to protect the provider from liability than anything else. I mean you can't MAKE someone sign it. Before I was a nurse I AMA'd out of an ER, no sign no nohting

Yes, they are exactly that. When people simply disappear, or walk out ranting refusing to sign anything, you just have to document, document, document ... using direct quotes of the patient's statements whenever possible.

[towntalker]

this may be manipulation but if the patient has been determined to be incompetent then that is what it is

this does not mean that staff should be allowed to be abused verbally or physically

if she were to insist that husband stay over night hand him ama papers

i have worked with these types both patient and fly members..the ones who state 'I KNOW MY RIGHTS' but they have no concern about the rights of other patients or the staff

[leslie :-D]

i agree.

the 2 main priorities are determining competency and legal guardianship.

the rest will fall on thorough documentation.

leslie