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.

[NightNerd, MSN, RN]

[ATTACH=CONFIG]24965[/ATTACH]

This is all I have to contribute.

[Been there,done that, ASN, RN]

Yes, giving him the cup of coffee crossed my mind as a possibility. But, in the moment, the way he was treating me and everyone else (including our brand new, nervous little 19 year old tech), made me want to do everything but give him the coffee. I was mad and angry at how he was treating me. Again, looking back on it maybe I should have just given it to him-but could that have made him stay longer in the day, and then I would have had to deal with him even longer?

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.

"but could that have made him stay longer in the day, and then I would have had to deal with him even longer?"

This is not about you, it's about the patient. You basically bounced out a patient that was not ready to go home, that even rescinded his own discharge and was visibly too weak to manage his own care... because your feelings were hurt.

Talk to your risk manager, make sure your malpractice insurance is in effect.

[Nurse SMS, MSN, RN]

We are trained not to bring patients P.O. anything without talking to the primary nurse, so those responses were correct. I am surprised at the replies to just give him the coffee, but yeah. Probably the right thing to do along with explicit documentation of education and I&Os. His behavior was abhorrent and would be difficult to cope with so give yourself some slack while at the same time thinking how you would do it next time.

The answer above about malpractice insurance is a bit over the top. You had an order to discharge, MD fully aware of the situation to the point of bringing him coffee herself and discontinuing drip and foley.

Next time I would just advise leaning into the situation instead of away. Bring the coffee or facilitate him getting it himself, document the n

Heck out of education throughout the shift and keep strict I&O measured and explicit documentation on behavior. Coach other team members to facilitate his wishes but keep fluid chart where he can see it (white board) along with statement written in simple terms of the pathophysiology of his condition - excess fluid =lung congestion =trouble breathing =hospital.

[Wuzzie]

I probably would have brought him the coffee in a cup with "R.I.P." written on it in sharpie.

[Double Dunker]

When I worked MedSurg, we weren't "allowed" to go over a patient's restriction.

Yep, us too. If the patient is unable to get up and get his own drink, then he's on a fluid restriction, tough cookies. If the doctor wants to lift the fluid restriction, then she can. But I can't.

If the doctor had already put in the order for the discharge, then that patient is going unless the doctor puts in a new order to admit. If the patient wants to sue because he wasn't allowed to change his mind, that's not your problem.

We had a patient situation sort of like this - patient signed out AMA and then changed his mind (after only being on the floor a few hours) The hospitalist told him to go back through the ER.

[Davey Do]

Oh, in hindsight we all could have handled the situation better.

I'm impressed with your self examination and admire you for being open to responses and criticism, NurseMom.

Welcome to AN.com! Glad to know you as a Peer!

[guest52816]

Sure you could have handled the situation better. But honestly, I think you did a pretty good job!

As several other posters stated, I would have given the guy the coffee after educating him as to why he was on fluid restrictions. I would have documented this, and probably called the MD. Then MD can then decide what they want to do with their patient.

This patient had a long history of non-compliance. They will continue to be non-compliant. Nothing will change.

You did the best you could while being verbally and physically abused. The comment about malpractice insurance is WAY over the top in my opinion. Not every patient is interested in improving their health, or even living.

[NightOwl0624]

Sure you could have handled the situation better. But honestly, I think you did a pretty good job!

As several other posters stated, I would have given the guy the coffee after educating him as to why he was on fluid restrictions. I would have documented this, and probably called the MD. Then MD can then decide what they want to do with their patient.

This patient had a long history of non-compliance. They will continue to be non-compliant. Nothing will change.

You did the best you could while being verbally and physically abused. The comment about malpractice insurance is WAY over the top in my opinion. Not every patient is interested in improving their health, or even living.

I agree. I'm surprised the OP isn't receiving more support from us, fellow nurses. I understand you have to pick your battles, but under the circumstances, this kind of patient to nurse abuse is not acceptable.

[NightOwl0624]

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.

I had to re-read the original post and to paraphrase:

.... Patient politely asks for coffee. Nurse politely states she will check his fluid intake. Patient becomes irate, cussing and throwing things.....

So.... Nurse has no right to refuse patient's request? For coffee???

Give me a break. Nurse has no right to refuse to do a lot of things, but running to get coffee for someone who just became abusive is not one of them. I don't think the nurse was wrong at all for trying to have a conversation and to double check things. Patient had NO RIGHT to become abusive, and once he did, the dynamics totally change. I'm glad he left.

(Just to add -I am not a coffee drinker, and I do get that some people really do love their coffee!)

[OyWithThePoodles, RN]

I have to respectfully disagree with the ones saying to just bring him the coffee. At the hospital I worked at if we would've gone against doctors orders of a fluid restriction we would've been in deep doo-doo. The fluid restriction is a doctors order. It would've been comparable to the MD ordering one Lortab and the patient saying, no, give me two. And throwing a FIT like a child until someone gave in to his request.

Yes, you educate. But in the world we live in, even documenting we did teaching sometimes isn't good enough if the patient ends up in fluid overload and then says "Well Nurse Jane just kept bringing me coffee every time I asked for it!"

Not only that, but you doing your job caused him to throw water at you. Unacceptable. You're lucky it wasn't the hot coffee.

What I probably would've done is called the doc and told him he was becoming belligerent and asked if the doctor wanted me to give him the dang coffee. Most docs I work with would've said no, they don't tolerate their nurses being verbally abused and let him go on his merry way.

ETA:If the fella wanted to have a friend bring him a drink, that's one thing. We can educate and then document what we see. But if WE are the one's bringing him a drink, that's a problem. We aren't following orders, plain and simple.

[Been there,done that, ASN, RN]

I had to re-read the original post and to paraphrase:

.... Patient politely asks for coffee. Nurse politely states she will check his fluid intake. Patient becomes irate, cussing and throwing things.....

So.... Nurse has no right to refuse patient's request? For coffee???

Give me a break. Nurse has no right to refuse to do a lot of things, but running to get coffee for someone who just became abusive is not one of them. I don't think the nurse was wrong at all for trying to have a conversation and to double check things. Patient had NO RIGHT to become abusive, and once he did, the dynamics totally change. I'm glad he left.

(Just to add -I am not a coffee drinker, and I do get that some people really do love their coffee!)

Feel free to take a break.

Use your assessment skills to look at the big picture. This is not about serving a patient a cup of coffee. This is about managing a patient that is declining doctor's orders.

Certainly, an alert and oriented patient does not have the right to abuse a nurse. The POINT is the nurse escalated the event.

"I'm glad he left." Why is that? So the nurse no longer has to deal with a mis-managed patient.. that is clearly unable to be discharged.. and asked to stay? You won't be so "glad" if he comes back in fulminating pulmonary edema and it was YOUR name on the discharge.

[Ruby Vee, BSN]

Feel free to take a break.

Use your assessment skills to look at the big picture. This is not about serving a patient a cup of coffee. This is about managing a patient that is declining doctor's orders.

Certainly, an alert and oriented patient does not have the right to abuse a nurse. The POINT is the nurse escalated the event.

"I'm glad he left." Why is that? So the nurse no longer has to deal with a mis-managed patient.. that is clearly unable to be discharged.. and asked to stay? You won't be so "glad" if he comes back in fulminating pulmonary edema and it was YOUR name on the discharge.

I'm going to go against the tide here. I've been in the OP's position, I discharged the patient and I re-admitted him ten hours later when the ER sent him back to our unit after he binged on a large pizza and a 12 pack. I have to say, he was far more cooperative the second time around -- seems like maybe the physician was right about the fluid restriction in the first place. Even though it was my name on the discharge, and even with at least 20 years of 20/20 hindsight, I still have no regrets.