Verbally abusive patient, worried I could have handled the situation better

[NurseMom2016]

Let me start out by saying this is a little long winded, but it has been weighing on me and I have to get it off my chest, so bear with me!!!

So, my last shift, I had gotten report on a male patient in his 60s, totally A&O, on our floor for anasarca. PMH of chf, alcohol and IV drug abuse, and hep c (from what I remember.). I work on a busy cardiac unit. This man had been sent to us from the icu on a bumex drip with a foley due to retention, along with a fluid restriction. He had to have assistance to get up, but could make it around just fine with his walker once up. The report I had gotten from the night nurse said he was a jerk, and noncompliant with the fluid restriction of 1000 cc among other things.

So first thing (before I had made it into his room), my charge nurse passes his room and he asks for coffee, she says she has to ask his primary nurse because he is on a fluid restriction. This sets him off, he begins to yell and curse so loudly, I can hear him from 2 rooms down through the closed door. So, then I go to the room. He politely asked for coffee. I politely said back, "ok, let me check the chart and see how much fluid you are at so far because you are on a restriction." This sets him off. He shoves his bedside table towards me, knocking off some of the remnants from his breakfast tray towards me. He begins to curse at me, saying things like "you stupid f***ing nurse" being the primary phrase. So, I calmly say "there is no reason to be this way to me, to be cursing at me. I will come back after you calm down." So I leave and close the door, and he is still cursing. About 5 minutes later, the tech told him that she would have to check with me before she could give him coffee, and he went off again, yelling and cursing so loudly that other patients and families were complaining. So, my charge nurse and I agreed we should call security. He arrives, and handles the situation well. The patient kept saying, over and over, "get me the hell out of here." So, in short, he ripped his tele leads off and began to pull on his IVs and foley. The physician came to the room and spoke with him, saying in short that he was welcome to leave if he did not want to comply with treatment, he could not treat staff that way, etc. so he agreed, yes he wanted to leave. The security officer and the physician said they agreed he should leave. So I removed the two IVs and the foley. While I am doing this, the PHYSICIAN brings him a cup of coffee and a cup of water (roughly 500 cc, he was already around 400 cc so far before this). While I was removing his foley, (he was sitting on the edge of the bed), he threw the cup of water over my head against the wall, but I was soaked. At this point I left the room fuming, and let the officer speak with him. He was saying he now wanted to stay since we gave him his coffee. THIS is the part I am questioning myself about-I told him "no sir, I have already removed everything and you have signed the paper to leave. The cab is on its way to pick you up." He did leave, and had to have assistance from the tech and officer to transfer from a wheelchair to the cab.

I had a hard time leaving some of the things he said to/about me at work that day. (I.e. You fata**, you shouldn't be a nurse, f***ing dumb nurse, I could go on). Remember, this man was as oriented as he could be, and was able to hold a calm conversation with others during this time. Probably some undiagnosed psych issues or something. I have never had anyone speak so poorly about me. So, yes I am glad he left within the first 2 hours of my shift, BUT my conscience keeps hanging on three things: one, that he wasn't able to walk on his own and we just sent him on his way. Two, that the foley was there for retention and it was removed almost immediately before he left. And three, that in the end I kind of told him he had to leave (I think he probably would have anyways).

Thank you if you have read this whole thing, I tried to condense as much as I could! Let me know what you think, if something could have been handled differently, etc.

[Possum_RN]

Also, I don't know how I missed that he THREW A CUP at you the first time I read this. Glad it was the water and not the coffee: at the hospital where I work, the hot plate keeps it scalding hot.

So no, do not feel bad AT ALL about telling him to leave even after he was calmed down. That was assault, and that was AFTER he got what he wanted. Nope nope nope: "bye, Felicia".

[CoffeeYogaNurse]

Do NOT feel about about this yahoo leaving. You didn't make him go. He's a grown man and if he wants to refuse treatment he can. You can't fix stupid and you can't teach him manners. "Here's your AMA form, have fun going into fluid volume overload with your venti PSL and don't let the door hit ya on the way out" would be my attitude all day about this one. Don't you waste a minute of worry on it.

You wouldnt go to his job and throw drinks, or curse at him, or be anything but a decent human, why is it allowed just because he's in the hospital and you're a nurse? You do not deserve to be treated this way as "part of the job", good for you for calling security! (Also whyyyyy did the doc have to undermine his own orders and give him the coffee?! Gah)

[Goldenfox]

This! ^

A lot of people you encounter these days are out of control, rude, and have a lot of issues. When patients start to act out like this, always redirect...specifically to their care needs and your role as the nurse. These days, much of the autonomy that we had as nurses has been removed by the customer service gods and goddesses who roam the hospital halls in suits and pumps. And, we must also accept the fact that not everyone who comes into a hospital with symptoms really wants to be helped. Best you can do is provide education and encourage compliance. If they are noncompliant with the ordered medical care plan, you document the details and notify the provider. And that patient should be discharged. What would be the point of keeping him in the hospital if he is going to keep drinking and going into fluid overload?

The doctor did the right thing. I would have given him the coffee, too. He would have kept on escalating otherwise. This guy evidently has a LOT of anger issues that have nothing to do with you. You were just an easy target for him to unload his verbal abuse. Given his history, he will be back soon anyway.

[NottaSpringChik, BSN, RN]

Any patient has the right to refuse a doctor's prescribed treatment. YOU had no right to refuse the patient's request. It's a hospital, not a jail.

Patients in jail may refuse care and are allowed the same privileges as any other inmate in regard to their food, exercise, etc. They receive education and special diet if desired, regular diet if desired. The down side for them is we are the manager of care so their choice is pretty much our care or no care and we will make them safe whether they want that or not. Would probably not be able to enforce a fluid restriction and it would probably be up the patient to do that for himself. We make people sign a refusal letter stating education was given concerning risks(given in the letter- disability, worsening if condition, death). Then it us on them pretty much. Bet your patient has spent at least a few nights in jail. Maybe hospital should get signed refusal documents!

[azzgirlRN]

"He was saying he now wanted to stay since we gave him his coffee. THIS is the part I am questioning myself about-I told him "no sir, I have already removed everything and you have signed the paper to leave. The cab is on its way to pick you up." He did leave, and had to have assistance from the tech and officer to transfer from a wheelchair to the cab. "

Did YOUR patient ask to stay?Was YOUR patient too weak to ambulate alone? So many risk factors and legal ramifications over a mis -handled cup of coffee request.

I think you haven't considered the fact that he "WAS" discharged. Once a pt has been discharged he/she needs to go through the entire process of being admitted once again, which means going through the ER. The doctor discharged the patient, not the OP. Orders are orders and 'just giving him the coffee' is not following the orders, period. Calling the Doc, advising of pt. requests, pt. abuse, etc. is the first thing I would of done besides documenting the heck out of the encounters with nurse and other staff, including the complaints from the other pts. on the unit. If the doc said give the coffee, so be it but it isn't up to you to 'just give him the coffee'. If the pt is that sick and is re-admitted, so be it as well, perhaps he will have learned that our job isn't defined by 'what the patient wants', but what the pt needs.

[sockov, ADN, ASN, BSN, CNA, LVN]

He was manipulating staff. You're too busy for that. He's being non compliant, so I wouldn't feel bad to have him leave. People like that usually don't get better. Now you have time to care for the ones that really need you and want to get better.

[mushyrn, BSN, RN]

Really, I probably would've just given him the coffee, as long as he remained nice to me.

But since you took the long road (which I'm totally for, too), once he started pushing his table at me and cursing at me like that, he would not have seen my face again until he decided to leave AMA and I was removing his IV/foley. And the moment he threw that water cup at me, I would've been talking to the cops about pressing charges, because that is wrong. I don't care how "anxious" or "powerless" he felt. Don't throw things at me.

So, AMA, and pressing charges would've been my response. Also, I couldn't care less about how appropriate or not it was to send him away like that. Leave. Bye. Go back to the ER if you have any issues.

[Spangle Brown]

I don't believe we should we rewarding and encouraging such behavior. By giving in, it only teaches him that if he escalates his behavior, he gets what he wants. Either he wants treatment, or he does not. Every PT we see like that, have learned that such behavior rewards them. Keep in mind, such a patient will NOT give you or your hospital a good review. And WILL take all your time running through hoops. Basically taking your time away from other Patients.

Your comment about looking at the record wasn't out of line, no matter what others said. He might be way over the amount he could have. Who knows, his behavior could have rewarded him all through the night with extra drinks. Better CYA, than be sorry. If he wasn't WAY over, then maybe, or maybe not.

The problem isn't wither he could have a drink. It was his response that is the problem. And shouldn't be rewarded.

Either way, he wasn't ready for treatment. When he is ready, he will come back. And hopefully he will know to behave better.

[hunnybaby24, BSN, APRN, NP]

This patient was being verbally abusive and almost physically abusive. So no, he isn't going to die when he leaves. He's most likely a non compliant rude gigantic PITA. You aren't there to coddle patients on their every whim. This isn't a hotel. He needs to learn he has a problem. That is why you are restricting fluids. Put your foot down and DONT give in.

[Munch]

Patients in jail may refuse care and are allowed the same privileges as any other inmate in regard to their food, exercise, etc. They receive education and special diet if desired, regular diet if desired. The down side for them is we are the manager of care so their choice is pretty much our care or no care and we will make them safe whether they want that or not. Would probably not be able to enforce a fluid restriction and it would probably be up the patient to do that for himself. We make people sign a refusal letter stating education was given concerning risks(given in the letter- disability, worsening if condition, death). Then it us on them pretty much. Bet your patient has spent at least a few nights in jail. Maybe hospital should get signed refusal documents!

Yup! My best friend is a charge RN at the county jail(LPNs do most of the hands on patient care, med pass etc..all RNs are charge at this jail) and while the medical provider can recommend treatment, order meds and certain diets they are then at the medical providers mercy when they don't comply. My friend tells me all time about this one 300 plus pound type 1 diabetic inmate that is on a special diabetic diet tray and this inmate she always comes down to get her finger stick and insulin and she is always almost over 400. Turns out she is always trading her tray for a regular one(diabetic trays get a lot of sliced turkey, shredded chicken, turkey burgers and hardboiled eggs so a lot of inmates actually prefer some of those choices as bland as they may be to some of the things served there I don't even want to know what) and she will take anyone else's that doesn't want it and eat it. Then of course she is the first to complain about the jails medical provider, how negligent they are, how the care they provide is horrible because her diabetes is out of control and how she is suffering from complications like neuropathy and how her sugar is always 400 plus and she equates all of this to the medical provider. My friend is not negligent..she is a darn good nurse. I guess it hasn't clicked that she needs to stick to her diet and lay off the crumb cakes and the cookies(inmates apparently can buy snacks and toiletries from the jail)..the correction officers tell my friend and her collegues all the time this inmate piles on the sugar and never sticks to her diet..but when she gets out she is suing the medical provider and jail for negligence. But just like OP patient..he wants his coffee but the second he goes into fluid overload he won't hesitate to get a lawsuit going against the hospital or the nurse who gave him the coffee. Sorry but no patient and his cup of coffee is going to cost me my job or a cent of my hard earned money.