Some answers to today's discussion.

I know I'm crazy to do this now, but if I don't, I may forget. SO I hope you are all reading this!!!


Why might the patient or family member be reacting this way?
Scenario A Isaiah may have joined a gang to have more control in his life. He may have felt angry at “authority” even before his accident. Now that he is in a wheelchair, he may feel he has even less control. Refusing treatment is a way of showing independence and strength.

Scenario B Victoria may or may not have “legitimate” back pain. She is angry because the physician is not willing to prescribe Oxycontin without knowing a complete history.

Scenario C Mr. Chou may feel that he has lost control. Refusing to look at his colostomy may be a form of denying the problem so he does not have to think about it. It may also be his way of gaining control. His reaction could be cultural as well, and he may feel that it is the staff’s responsibility, not his, to care for his physical needs.

Scenario D Ms. Reed probably feels overwhelmed by her father’s decline in health. She may have unrealistic expectations for his recovery. She may also feel that the hospital is only interested in money and not her father’s needs.


What does the health professional expect or need from the patient?
Scenario A The physical therapist expects the patient to understand that wearing the boots is in his own best interest to avoid foot drop.

Scenario B The physician has legal and professional obligations. He wants to help Victoria get better. He also wants Victoria to be honest with him so he can help her.

Scenario C The nurse wants Mr. Chou to take steps toward learning to care for himself.

Scenario D The discharge planner wants to discharge Mr. Johnson within the time constraints and to provide him with the best care possible.


How might the health professional handle the situation?
Scenario A The physical therapist should avoid taking Isaiah’s behavior personally, but rather use Isaiah’s need for control as a strategy for getting him to wear his Spenco boots. Isaiah needs to believe that wearing the boots is his own idea. The therapist might agree that the boots are ugly, but also add that having permanent foot drop is even uglier. The therapist might ask Isaiah to work out a schedule that will allow him to wear the boots when people won’t see them. (Spenco boots are normally worn at night anyway, but if Isaiah chooses this schedule as his own idea, he may become more compliant.)

Scenario B The physician might show empathy for the patient and acknowledge her frustrations, but he should also explain his reluctance to prescribe Oxycontin, a drug that is frequently abused, without knowing more about her history. Without accusing her of seeking narcotics, he could say that in order to comply with his legal and professional responsibilities, he needs to be assured that she has not been taking Oxycontin inappropriately. He can tell her that before treating her, he needs to establish a trusting therapeutic relationship, which requires her trust in allowing him to speak with her previous physician. He might also tell her that no matter what the physician says, he will promise to give her the best treatment he can (which may or may not involve prescribing Oxycontin). If he then discovers that she has a drug abuse problem, he may offer her treatment for her dependency, but refuse to provide her with Oxytocontin.

Scenario C At this time, the nurse should shift her conversation with Mr. Chou away from teaching colostomy care and toward helping him look at and accept his colostomy. Very likely, Mr. Chou needs time to adjust to his new body image, as well as to the fact that he has terminal cancer. As Mr. Chou watches her care for the colostomy, she might ask more general questions about his plans for when he returns home. Later, the nurse should start a care plan that outlines how to provide teaching. To develop the plan, the nurses will have to discuss with Mr. Chou and concerned family members how his colostomy care will be provided. The plan might involve either getting Mr. Chou to learn his own care or having another family member learn to assist him to do his colostomy care.

Scenario D The discharge planner is in a difficult position. Discharge planning should start on the first day of hospitalization and should be continued throughout the hospitalization, so that the patient and family have ample time to prepare. It may be that Ms. Reed was aware of her father’s upcoming discharge, but has been in denial about what taking care of him will entail. The reality of discharge may also have forced her to acknowledge her father’s failing health.

The discharge planner should allow Ms. Reed time to express all of her fears and concerns about caring for her father at home. The discharge planner should acknowledge to Ms. Reed that it may be difficult for her to accept that her father’s health seems to be failing. It may help Ms. Reed if the discharge planner asks, “If your father is no longer benefiting from hospital treatment, do you think it’s better for him to be at home or in the hospital?” She should also assure Ms. Reed that she will inform the home health care agency of her concerns so that the visiting nurse will ensure that Ms. Reed gets the assistance that she needs to care for her father.