What would you do if this was your patient?

what is the doctors order for tx time? We don't fool with that, so if they have a 4 hour tx that's what we set. If they want to leave early they have to sign the AMA form.

Never ever fool with the tx time.

Tx time is 3 hours but he can somehow manipulate the staff into giving him 2 hours. When he had the cramping and low bp episodes when I was handling him, I spoke to the doctor and told him what happened. He gave a telephone order not to remove more than 1kg per hour. But he doesn't care about his doctor's order. He also said he can't sit in the chair for 3 hours.

The patient does have a right to cut his treatment time, (if he signs the AMA form) but he does not have the right to override the doctor's order for more then 1kg an hour. So if he wants 2 hours, then 2 kg. He cannot set the machine himself, he is manipulating the staff to do this. Sounds like what needs to happen is a behavioral contract of some kind. You put together a short list of rules, make him understand that if he does not stick to this, the doctor also has the right to not treat him. Maybe ask the social worker if they have done this in the past with anyone.

We used to have a guy that was supposed to show up for treatment at 1330. Sometimes, he didn't show up until 1600. He would get one hour or 1.5 hours of treatment. We had to make him sign a contract that he understands what being late is doing to his health and that if he did not improve his behavior, we may not be able to care for him. It also said that we had no obligation to start his treatment if it was after 1600. If he hadn't showed up for treatment more then twice, we had the right to refuse to take him due to potential instability of labs. Eventually, we had to terminate the relationship with the patient and the clinic helped him find a new clinic. But the doctor did not want this behavior risking everyone's practice.

This behavior is manipulative and controlling, but remember, no matter how much he insists, you have a doctor's order and you cannot override this. he has the right to cut his time, but he cannot override doctor's orders and change his own prescription without the doctor's permission. Would you let a patient demand that he be on a 2K bath? or that you put him on a sodium profile? What if he demands heparin that isn't ordered. The UFR is no different. This is a doctor's order. It sounds like instead of refusing to put him on, you need to find a way to set limits with his behavior and remind him that this is completely out of your control.

Thank you for that thorough response. After he learned that I carried out the doctor's order, he actually got mad at me and blamed me for changing his prescription. I told the social worker to explain to him that I only was only carrying out doctor's order. He became verbally aggressive towards me and my FA told me not to handle him anymore to prevent any mode issues. So he's still doing what he's been doing - but with other nurses. I'm just glad that I was able to stand up for myself instead of getting manipulated by him.

Thank you for that thorough response. After he learned that I carried out the doctor's order, he actually got mad at me and blamed me for changing his prescription. I told the social worker to explain to him that I was only carrying out the doctor's order. He became verbally aggressive towards me and my FA told me not to handle him anymore to prevent any more issues. So he's still doing what he's been doing - but with other nurses. I'm just glad that I was able to stand up for myself instead of getting manipulated by him.

I've read that this will cause cardiac distress in the long run

The current thinking is that UFR should be no more than 10-13 ml/hr/kg to protect cardiac function (yeah, good luck with that)

I doubt the doc would cut his time to less than 3 hrs, but if his labs are okay at 2 hrs maybe he could drop to 2x week. If not SOB, maybe raise dry wt? What about PD or home HD?

You could give him a brochure on headstones and ask him if he's selected one yet.

The current thinking is that UFR should be no more than 10-13 ml/hr/kg to protect cardiac function (yeah, good luck with that)

I doubt the doc would cut his time to less than 3 hrs, but if his labs are okay at 2 hrs maybe he could drop to 2x week. If not SOB, maybe raise dry wt? What about PD or home HD?

Hi AcuteAlan, he tried home HD in the past but he was very noncompliant so they took him off the program and put him back to in-center instead. His labs are not okay. He barely meets adequacy.

You could give him a brochure on headstones and ask him if he's selected one yet.

Lol, funny but our goal here in dialysis is to extend our patients' lives. Now if everytime he dialyze, we put him more at risk for death then that is defeating the purpose of dialysis.

Welcome to dialysis, Chisca's advice is on the mark.

BTW, you did the right thing in sticking to the orders. Sounds like the FA needs to have a coming to Jesus meeting with the rest of the staff. This pt is a walking time bomb, if he goes bad on a machine and the UFR is set at nearly double the prescribed rate, I wouldn't want my name on that run sheet.

This is ridiculous! The staff ALL need to follow Drs orders when putting patient on the machine. If his prescribed time is 3 hrs, he must be set for 3 hrs!

Then, if he wants to sign off AMA, it won't reflect badly on the staff. The other issue is that he won't get all his fluid off, and may end up in Pulmonary edema requiring a trip to the ER for an emergent treatment

Sometimes, these hard headed patients have to experience the consequences of their behavior before they become more compliant.

Document every single statement made by this patient and his attempt to bully staff.

A care plan meeting needs to happen, also staff education in always following Drs orders!