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

NightOwl0624 · Sep 21, 2017

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.

Please explain how the nurse acted to escalate this?

Once he changed his mind after he was discharged and iv and foley were removed, he could have gone back to the ER.

Alert and oriented people are responsible for their actions.

chacha82, ADN, BSN · Sep 21, 2017

Time to get your charge RN/DON/floor supervisor involved with all of the aspects of this situation that made you uncomfortable. Do you have a debriefing process in place for difficult situations like this? I would also invite your coworkers so everyone could get on the same page about policy.

1) What is the FR policy at your facility? Get everyone on board. If the doctor is going to bring in coffee when he is over his FR, what is your obligation? I would emphasize the MD brought him coffee, since this is who you would notify anyway. Get a hard line policy in place for the unit. Is it adhere no matter what, or educate, document, notify?

2) What is the policy for patients who have been discharged and then decide to stay? If another situation arises, what is the facility expectation? Notify MD and put a hold on discharge? Or direct patient to ED?

Some of the best advice I have ever gotten is 1) never get into a power struggle with a patient and 2) do not let the need for a patient to "like" you affect your duties as a nurse.

Ruby Vee, BSN · Sep 21, 2017

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.

You've gotten mostly posts disagreeing with you, and you've been very open to the criticism. I have to tell you that I think you've taken the specific verbal abuse your patient heaped upon you too much to heart, but I don't disagree with what you did. The patient wanted to leave and the physician wanted to discharge him. You discharged him.

I don't think the whole issue was coffee . . . I think he was far enough into his hospitalization that he'd been without alcohol or his other drugs of choice for long enough that he was nearing withdrawal. He wanted to get to the tavern, the liquor store or home, where he had his stash. Giving him coffee would not have solved the problem. It might have solved the IMMEDIATE problem, but after he drank the coffee (and it made him even more jittery) he would have had a tantrum about something else. And then something else again.

I think you did the right things. The only thing I would have done differently is considered alcohol withdrawal, probed a bit to determine whether that could have been a factor and maybe alerted the physician to consider ordering whatever your facility's alcohol withdrawal protocol calls for.

Been there,done that, ASN, RN · Sep 21, 2017

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.

"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.

OyWithThePoodles, RN · Sep 21, 2017

"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.

But the patient had been discharged, and he himself signed the papers. A patient can't decide they want to stay after a doctor has discharged him, regardless of the reason. Had he not signed the papers he would have a leg to stand on so to speak when appealing his discharge. What OP could have done, is wheel him right back around to the ER. He threw his fit, got what he asked for (to be discharged) so now he should have to pay the second ER bill (in my opinion).

Ruby Vee, BSN · Sep 21, 2017

"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.

My patient was in CCU, three hours after a femoral heart cath with three hours more to lie flat. He didn't want to stay, he wanted me to go home with him and "take care of" the organ he produced every time we wanted to check his femoral arterial site. The cardiologist told him in no uncertain terms that he was being inappropriate and disrespectful of the staff and making well-informed but unintelligent choices about his healthcare. I think the words "Go now, and you'll be back before the sun rises" were used. The patient allowed as how that would be acceptable to him, but wheedled for incentives to stay . . . beer, the aforementioned sexual priveledges and even some THC to "take the edge off." As I wheeled him out of the hospital in his gaping hospital gown (he didn't want to "confine the dick" in the filthy jeans he came in wearing and refused to wear the robe provided) he kept up a running commentary on the size of my breasts and the recreational activities he could engage in "with a rack like that." I was delighted to see him go.

I'm not convinced that the coffee request was mishandled. I strongly suspect that after he got his coffee, he'd come up with something else to have a tantrum over. I think he was THIS close to DTs, and the only thing that would have "saved" the situation is a whopping dose of Valium, Ativan or whatever her facility's protocol calls for.

Emergent, RN · Sep 21, 2017

I agree with the nurse you got report from, he's a jerk.

I would have probably just allowed him to be noncompliant and charted his behavior. I think the doctor was a jerk in the situation too, to make you look like the bad guy.

The man is a fool and I try to avoid arguments with fools.

Ruby Vee, BSN · Sep 21, 2017

But the patient had been discharged, and he himself signed the papers. A patient can't decide they want to stay after a doctor has discharged him, regardless of the reason. Had he not signed the papers he would have a leg to stand on so to speak when appealing his discharge. What OP could have done, is wheel him right back around to the ER. He threw his fit, got what he asked for (to be discharged) so now he should have to pay the second ER bill (in my opinion).

I agree with you.

pixierose, BSN, RN · Sep 21, 2017

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.

How did the OP escalate the event?

I guess I'm confused here; with our patients on fluid restrictions, I would need a physician's order to *not* follow said protocol.

Get the patient his damn coffee: potentially get in trouble for not following the patients care plan.

Not get the patient his damn coffee: now you're escalating the situation?

We are all human. I wouldn't feel too bad for him leaving either.

As for d/c ... now the patient is in a power play over d/c and admission. Once the orders are in at my hospital by the physician, the papers are signed by all parties, etc that patient is out. This patient would need to be readmitted all over again. Since he is A/Ox4, nothing is preventing him from going back to the ED.

JKL33 · Sep 21, 2017

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.

Bottom line, right here. ^

OP, Sorry you had to deal with all of that. I'm not going to critique your every move except to say that in general I have learned to stay super calm (inside) and take none of these types of situations personally (because they aren't personal). It wasn't easy to learn. We cannot accept responsibility for every problem that someone else has. Thinking that we can is kind of non-sensical if you think about it. "Inner peace" in the face of these situations will increase the odds that you might be able to help change the situation (you will choose your words carefully, remain aware of your non-verbals, etc., and possibly even build a rapport in near-impossible situations. And...if none of that pans out, at the very least you will be comfortable with how you handled it at the end of the day, and be at peace emotionally.)

A few other thoughts:

"Dr., your patient So-and-so is screaming profanities and throwing things; he is upset about his fluid restriction. I need someone to come and reassess the situation." [Note that if someone is going to refuse an important aspect of care, then simply cancelling the order without re-assessment is often not appropriate. So, I would've pressed until admitting service agreed to visit the patient in person.]

Check your AMA form. Many of them are not only for an AMA discharge, but also for refusing any important aspect of care. I utilize these whenever they are appropriate! You could simply give the patient coffee (since he does, indeed, have the right to refuse aspects of his plan of care), but then he could turn around and say that no one explained why the fluid restriction was important. Utilize the AMA process (which includes assessing pts' understanding and knowledge of the issue in question). The AMA form and the process are your friend in situations exactly like this one.

I, too, would've facilitated the discharge even after he "changed his mind." Same reason I have zero problem with the hospitalist giving him coffee - he is discharged. No one threw anyone under the bus. She told him he is discharged if he doesn't want treatment, and that he may not treat the staff this way. Who cares if he has coffee on his way out the door.

Here's a (hug). Tomorrow's a new day.

Julius Seizure · Sep 21, 2017

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?

Yes, I understand not wanting to give him the coffee too! But that thinking turns it into a power struggle, and that is just going to make your day harder.

I can definitely see both sides of the "just bring him the coffee" argument. However, if the motive behind it is a power struggle, its not going to help anybody.

DTWriter · Sep 21, 2017

Now, the following is...sort of on topic:

Suppose this patient were to return and end up on the OP's unit, again...Can the OP refuse to be his nurse, especially since he assaulted her during a previous admission? Or, even if he did not assault her but was verbally abusive while A&Ox4?