What would you do if this was your patient?

[foxy1112]

Hi, I work as a dialysis nurse for less than a year. We have a young patient who hates coming for treatment so what he tries to do is .. He would try to remove 3.5kg for 2 hours. After a while when he starts having cramps and hypotension, he will ask staff to take him off from the machine. I've read that this will cause cardiac distress in the long run. I tried to educate him and his wife but they won't listen. They think they know better about dialysis than the rest of us. One day, I spoke to our nurse manager and told her I don't want to put him on anymore because I want to protect my license. Am I overthinking the situation or did I do the right thing? What would you do if he's your patient? Thank you.

[Twinmom06, ASN, APN]

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.

[foxy1112]

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.

[NurseRies, BSN, RN]

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.

[foxy1112]

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.

[foxy1112]

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.

[AcuteHD]

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?

[Chisca, RN]

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

[foxy1112]

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.

[foxy1112]

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.

[AcuteHD]

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

[AcuteHD]

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.