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

Mulan · Sep 22, 2017

Almost everyone is focused on the cup of coffee and that is not what the OP is concerned about.

This is:

quote from NurseMom2016

" 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. "

Ruby Vee, BSN · Sep 22, 2017

I don't think it would have mattered if he'd been given a cup of coffee or not been given a cup of coffee. Five minutes later it would have been something else. The guy is on a collision course with destiny and at this point I don't think it's a matter of education.
The doctor gave him his coffee after she told him he was discharged; I agree it was her way of telling him she was washing her hands of him. Changing his mind about discharge after getting his coffee was just being manipulative and all the abhorrent behaviours would have just continued. I don't blame the OP for not allowing that and sending him out the door.
Having worked psych for the first half of my career, there is one thing I always tell students and orientees: "You can't save someone from himself and it does no good to work harder for someone than he is willing to work on his own behalf".
This is the kind of patient that always leaves you second-guessing yourself because they like to create lose-lose situations. It's unfortunate but you have to just shake it off. Hugs.

I agree with you that five minutes later it would have been something else -- there are no indications that he hadn't been educated or that he hadn't agreed to the planned fluid restriction.

I love your quote: "You can't save someone from himself and it does no good to work harder for someone than he is willing to work on his own behalf."

Ruby Vee, BSN · Sep 22, 2017

What is your plan when "later" becomes now? Yes, it's slightly possible that some negotiations or concessions may have improved the OP situation. Very slightly, as in - probably not, but I'm not willing to say 100% impossible, and I would at least try. Lets acknowledge though, that patients who would negotiate with you like reasonable human beings are not usually the ones calling you a stupid, lazy, effin' fatass.
Here's the second problem - which has always been the problem with customer service as it relates to patient satisfaction as it relates to things that make patients happy: We're not talking about restaurants or free pickles. We're talking about something that is medically contraindicated (and I'm not going to argue about how necessary fluid restrictions are; the fact is that currently they are generally an accepted part of a plan of care/standard of care for such a patient, which is why the physician ordered it in the first place).
I have no problem with patients refusing aspects of their care or asking for concessions, such as cups of coffee, that may be medically contraindicated. But I think that they should take full responsibility for that, as opposed to making medical providers "give them a pickle." When patients receive care that is out of line with accepted standards, the care team generally retains legal responsibility for that. Conceding while retaining the legal responsibility goes well beyond "customer service." It's pretty disingenuous to conflate the two. This is a hospital. I don't care what the non-medical patient services people say, customer service is not things that are medically contraindicated. Don't you know -- Medical errors are ((supposedly)) the third leading cause of death in this country...?
So which is it? We're killing practically everyone, or we should give people pickles that are medically contraindicated?

The "customer service pendulum" has swung so far that we're now happily providing patients with liquids, foods, options that are medically contraindicated. And it seems that many of us nurses don't see the problem with just giving the patient whatever he asks for. That's good customer service, you see, and it obviously trumps good patient care for many nurses. Or maybe it's "give him what he demands so he'll shut up and my shift will go more smoothly."

The original poster handled things just fine from the refusal to bring the cup of coffee to the refusal to let the manipulative donkey stay after he'd officially been discharged. Some of the rest of us . . . not so much.

RestlessHeart · Sep 22, 2017

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.

I so love almost every one of your responses. I may have to start stalking you (so I can learn more of course). Thanks for speaking out.

RestlessHeart · Sep 22, 2017

At the risk of getting my "membership" here handed to me on a platter..Id like to ask something. Please keep in mind I am not and never was a Nurse of any degree. I do have great respect for all of you in the Medical Field. My Medical side is only extensive as far as the patient view because Ive been one way tooooo many times.

Anyway... I digress. Just be gentle ok? Im curious about the fluid restriction and how that comes about. How is it decided and who decides how much of a restriction is applied? Does it mean ANY fluid? Is it "touchy" (where a little too much or a little too little can be nasty?)

My twin has kidney failure and when she was hospitalized and later in a Nursing rehab prior to going home they had her on fluid restriction. But...here's the thing I never understood. She would leave the clinic / dialysis and almost immediately drink 2, 16 ounce bottles of Mt Dew. Mind you she is a raging diabetic that believes you can eat or drink anything as long as you take the insulin. UGH.

Anyway....I appreciate any responses...just be gentle.

Have a super day and I wouldnt wish the treatment the patient OR the nurse received in this matter on ANYONE!!

Creamsoda, ASN, RN · Sep 22, 2017

Maybe the only thing I would have added was, " sir you are discharged, but if you think you need to you can go to the ER". Sure it could be easier to just resign and let him stay once he had his coffee, but that would be reinforcing his terrible behavior. We can still give him the care he wants... but after he goes back through the ER. Sure its a pain, and a big waste of resources, but just because its a hospital, doesn't mean he gets a free pass. Anywhere else in society if he doesn't follow the rules, he has to live the consequences. He was alert and oriented. And assaulted you by throwing stuff at you. Which you could certainly press charges for.

TriciaJ, RN · Sep 22, 2017

At the risk of getting my "membership" here handed to me on a platter..Id like to ask something. Please keep in mind I am not and never was a Nurse of any degree. I do have great respect for all of you in the Medical Field. My Medical side is only extensive as far as the patient view because Ive been one way tooooo many times.
Anyway... I digress. Just be gentle ok? Im curious about the fluid restriction and how that comes about. How is it decided and who decides how much of a restriction is applied? Does it mean ANY fluid? Is it "touchy" (where a little too much or a little too little can be nasty?)
My twin has kidney failure and when she was hospitalized and later in a Nursing rehab prior to going home they had her on fluid restriction. But...here's the thing I never understood. She would leave the clinic / dialysis and almost immediately drink 2, 16 ounce bottles of Mt Dew. Mind you she is a raging diabetic that believes you can eat or drink anything as long as you take the insulin. UGH.
Anyway....I appreciate any responses...just be gentle.
Have a super day and I wouldnt wish the treatment the patient OR the nurse received in this matter on ANYONE!!

Here goes. Your twin is a classic example of someone who is not following her prescribed treatment. "Raging diabetes" quite often leads to kidney failure. That means her kidneys can't get rid of excess fluid or do any of the other things that kidneys do, like help control blood pressure. The fluid restriction is to lighten the load on her kidneys and prevent all the other bad things that happen when our bodies are in fluid overload. One example is literally drowning when our lungs fill up with fluid and our hearts are unable to pump properly.

When your sister gets discharged and promptly starts drinking Mountain Dew, she is taking in fluid and sugar that her body is unable to handle. ALL of her problems start getting exponentially worse. Her caregivers know that.

One of the first things drummed into us in nursing school was a quote by Florence Nightingale: "Above all, do no harm." That means even if we can't make the patient better, we should at least not make him worse. The corporate bean counters and customer service gurus don't get that. They don't get that a pickle, or Mountain Dew or a cup of coffee can actually hasten someone's death and why nurses can never function like a concierge at the Hilton.

Your sister is committing suicide the slow way. Nurses know that, even if it is not apparent to others. If you discovered her trying to hang herself, would you be nice and help her tie her noose, or be a mean sister and take away her rope? Think of nurses as the mean sisters.

Creamsoda, ASN, RN · Sep 22, 2017

Kooky...
Come on, you don't really mean that, do you? She'd already discharged the guy, after telling him that he may NOT treat staff that way.
I'll take that for support, in a heartbeat. I would've brought him the coffee myself at that point, seriously.

Yeah I didn't think the doctor is as evil as everyone is making them to be either? The way I understand it as written, doc told the guy to quit acting like an idiot and that yes he may go home if he wishes. Told him he is discharged per the patients wishes. Then while all that is getting ready to go, brings the guy coffee while he's waiting for a cab to help de-escalate the situation more. He's discharged, he can drink what he wants. I would have got the coffee too at that point.

Though to be honest, I don't care if a patient is having a hissy fit, if they want to break all their restrictions, i am not going to stop them. You want cream and sugar with your coffee? Thats where I think OP maybe took things too personally. You just chart that the patient is not following restrictions. We can't force them. They want to fluid overload themselves while alert and oriented? Go right ahead, ill be at the desk when you go into flash pulmonary edema and code and will help you then because then its implied consent to save your sorry life. And I will continue to get as much overtime as I do because these people give us job security. =D

Here.I.Stand, BSN, RN · Sep 22, 2017

@RestlessHeart --

Fluid restrictions are prescribed for patients whose heart function (or in your sister's case, kidney function) is compromised too much to be able to handle unlimited fluids. In a nutshell, pt drinks excess fluids, fluids absorbed into the bloodstream; the blood volume increases, but the heart is too weak to keep up with pumping the extra volume/kidneys unable to filter all of that volume. The excess fluid leeches from the blood vessels, which causes edema. The big danger isn't cankles though -- it is pulmonary edema, which is like partial/gradual drowning.

The restriction amounts are usually between 1 and 2 liters per day -- depending on the degree of heart failure. This is entered as an order/prescription as part of the medical plan of care.

The OP's patient and your sister may not follow the recommendation and that is their right. However as health professionals, *we* can't be compelled to ignore the plan of care which compromises his/her safety. It's one thing if their family gives him bottled drinks from the store -- it's their legal property and we can't confiscate it. However, this pt threw a toddler tantrum because the licensed professional RN chose to follow the POC.

He could possibly have been able to drink the coffee. If he got 2000 ml of fluids per day, he'd drank nothing overnight, and had 120 ml of juice with breakfast -- sure, he has room for a 240 ml cup of coffee. But was he limited to 1000ml per day, but he had juice with breakfast PLUS half his water pitcher is gone? Midnight is a long way off, and he will get VERY thirsty, because the nurse isn't going to procure drinks once he's had 1000 ml. So the OP was absolutely correct to check his chart first. Say that coffee put him to the top of the fluid limit, he had every right to be informed up front that staff couldn't bring anything to drink until after midnight. Unfortunately, instead of being reasonable he chose to act like a 2 yr old and throw things at the nurse. :no:

Snels50 · Sep 22, 2017

What could you have done differently? Considered alcohol withdrawal in your differential. Big missed diagnosis by the doc.

BSN16 · Sep 22, 2017

Sometimes our patients are having the worst day of their lives. They're frightened, they're frustrated, and acting out may be the one way they have of feeling like they have some sort of control. As much as it may not look that way, in our relationships with our patients, the power is disproportionately ours, and that can be hard to swallow for the one without the power. Indeed, we sometimes feel like we are powerless and have to kowtow to get those patient satisfaction score, which makes us want to act out a little, too.
In times like these, it's very important to understand that people may be dealing inappropriately with their anxieties and stress because they just don't know any other way. Nor is it wrong to step away a moment, take a cleansing breath, and keep in mind that some of these people were probably jerks long before we ever met them, and will be long after they're discharged.

I have had my number of patients and their families coping inappropriately. however i think this mentality is dangerous because it normalized verbal and physical abuse from patients. Yes they are in a stressful situation but no, this does not give them the right to treat staff this way. In my opinion throwing the cup of water and getting the nurse wet boarders on the line of physical assault whether intentional or not.

OP i dont think you could have handled this situation much people. These patients are difficult and sometimes make us question why we became a nurse in the first place. Just remember that for every ungrateful angry patient there are a 100 appreciative patients in their place.

Julius Seizure · Sep 22, 2017

So you would have given in to his babyish demands and not followed orders? That would leave you open to claims of negligence or malpractice I think because you handed him the coffee or whatever liquids.

This doesn't ring true to me. Patients can refuse treatments. Are you saying that if I go to insert an NG tube on a patient and they say they don't want that treatment, that I am at risk of negligence/malpractice? Or if I offer a patient their enalapril and they say they don't wish to take their medication, that I am open to negligence/malpractice? I think not. If the patient refuses a treatment, then my duty is to educate, document their refusal, and update their attending provider on the patient's wishes. Not to force them to accept the treatment.