What would you do?

[sticknurse]

I am trying to care for a young man in him home. He is considered to be his own responsible party. The problem I'm having is he is not good about taking any initiative with his own health needs. For instance, he constantly refuses assessment, "no one takes my vitals", also, he has fired other nurses for calling the doctor with legitimate concerns. He fails to maintain the supplies necessary to adequately care for him ie. gloves, catheters, etc. There is almost no family support, only a mom who we may or may not be able to get hold of. He denied her existence at first, then another nurse told me about her. I thought he had no back up caregiver at all. He has sort of a reputation and only one nursing agency is even willing to send staff in to see him, he has also been known to send a nursing assistant away or tell her her services won't be needed, then turns around and expects his homecare nurse to perform the aides job, which wouldn't be so bad except we are only authorized to spend an hour with him and only allowed to provide a specific NURSING service, not everyone's duties. Further problems arise when he surprises us with these requests and we must choose to make him happy or keep other client's visits on time. He has become a problem also due to his failure to be honest with us (the nurses) about new orders and refusing to answer legitimate nursing questions as in "Have you been eating?" Or 'How is your pain?" This client's attitude ranges from ignoring the question altogether to outright hostile responses. I am at my wits end. Any suggestions? Sorry so long.

[jnette, ASN, EMT-I]

While patients have rights, they ALSO have responsibilities.

Our agency has these rights and responsibilities printed out and these are explained to potential patients at sign up. (SOC)

Sounds like your agency might need to contract with this patient and hold him to his end of the deal. If he does not, he will have lost another opportunity for care, which he may not WANT, but may NEED.

He may well be alienating himself from any future care...and may not realize how this might effect him in the long run down the road.

Has he had MSW intervention? This is a sad situation.

[caliotter3]

He sounds very familiar. I've encountered a few like him before. Usually the agency just puts up with their behavior, depending upon how badly the agency needs the business. As an individual, I would make a decision regarding how much of his behavior I would tolerate before asking to be removed from the case. I usually draw the line somewhere where I believe that I am somehow jeopardizing the status of my license by allowing him to play change up on me, or when I find myself getting ill just thinking about working with the patient, or I am spending too much time doing CYA documentation in relation to what should be going on. When every shift requires some kind of memorandum or extra work that is just too much. Your sentence about him getting rid of nurses because they have communicated with the doctor did it for me. If I were informed about this prior to starting this case, I wouldn't even bother to take it. He has his rights to do what he wants and we have our rights to not be placed in his impossible position. Where I came from patients like this would develop reputations in the home health community and even if they could find an agency willing to take them on, they would find it very difficult to get any nurses, because their reputation would precede them.

[GYPSY1349]

there are a couple of issues going on here. first, if this is a medicare patient, medicare requires (legally) that there be a "willing and able caregiver" available to help coordinate and manage the patient's plan of care. have you tried contacting this patient's mother or other relative?

additionally, you and your agency are not obligated to continue care on a non-compliant patient. to do so, places your license and your agency's accreditation in jeopardy.

your first line of defense is to speak with your clinical nurse manager about the issues of lack of caregiver, and the patient's non-compliance, risks he faces, etc. concurrently, you should contact the patient's physician immediately, and make sure you speak to the doctor's assistant (nurse), not the receptionist, and clearly outline the problems you are encountering, which place the patient at risk.

there are, unfortunately, many agencies that will accept any patient, and keep them on the books endlessly, while no real nursing skill is being performed. there has to be documented nursing skills for each visit, other than routine vital signs, for legal medicare or private insurance reimbursement. i would address these issues with your nurse manager as well.

in my opinion, having worked home health as a case manager for many years, this patient is ready for discharge, as he is non-compliant with the plan of treatment.

[sticknurse]

Thanks everyone for your input. I am an independent nurse and he is a medicaid client. The case manager is an RN and well aware of the situation, however since he "fired" (he thinks) her the last time she tried to remind him of his responsibility she is not too happy with him either. His own mom is a social worker and she is fed up with him as well, even though she is listed as the back up caregiver, she has stated that she doesn't want to be his go to person because of ongoing abuse she has experienced. He is difficult on a good day. The doctor is aware of his noncompliance, yet it goes on. I am pretty sure I just need to get myself off this case. Thanks for the input and advice again.