Managing Disruptive Patients _ ________________________________________________________________
CASE STUDY #2 Michael Longfellow is a 60-year-old male patient who was admitted to the hospital after he fell and broke his hip. He had been helpless at home for several hours after the fall because his wife was away from the house. When she returned and found him, he was immediately brought to the hospital by ambulance. On the day of admission, surgi- cal repair was performed. After surgery, Michael was disoriented for several days. He was confused, belligerent, and had visual hallucinations. Medication for agitation was required some of the time. Michael’s blood pressure and pulse rate were high. Eventually, his mental status cleared and the remainder of the postoperative period went smoothly. Michael’s incision began healing and his vital signs became stable. Pain management, however, remained a problem for Michael; it was difficult to develop a pain management regimen that enabled Michael to experience pain relief. He was unwilling to practice coughing or deep breathing as recommended because of reported pain. It was a constant struggle to assist him with ambulation exercises, although he had been informed of the dangers from immobility many times. He developed pneumonia and his hospitalization continued. His wife and adult children rarely visited and were unwilling to talk with staff members. Michael reported that he had not worked for years and relied on his wife for much of his care and support. He gave vague reasons for this situation, stating that he had been laid off and that there were never any jobs in his field of employment. The healthcare professional staff began to be concerned as time passed and Michael did not appear to be assuming responsibility for his recov- ery. He, on the other hand, was eager to return home and pressured his physician to let him go prematurely. The staff called a patient care conference to discuss the discharge plans for Michael. During the conference, several of the healthcare professionals on the evening shift expressed concern that Michael would not be well taken care of if he were to return home at this time. They had met his wife because she visited in the evening after work. They described her as “cold” and “mean.” They were sure that she would provide no assis- tance to Michael, who would be forced to fend for himself at home. The night healthcare professionals described ongoing episodes of insom- nia that the patient had experienced since his admission. One of the healthcare professionals had found Michael attempting to smoke in his room. She stated that he drank cup after cup of coffee whenever he could. She thought that he was simply a patient who was nonadherent with his treatment plan and should be discharged as soon as possible with home care assistance. One of the healthcare professionals mentioned the possibility that Michael might have an alcohol use disorder. She cited his delirious episode after admission, his low pain tolerance, and the dysfunction in the family as possible indicators that he might have a substance use problem. The physician added that the hypertensive episode after surgery and the insomnia supported that assessment.
HOLISTIC CONSIDERATIONS Patients do have the right to choose their own treatment and make their own decisions unless their choices will harm themselves or others. However, healthcare professionals and other clinicians may have a better knowledge base about treat- ment options. The healthcare professionals’ role is to educate patients so that they can make an informed choice and not to assume patients do not know what is best for themselves. Walker (2017) outlined four basic philosophical orientations for clinician-patient relationships related to adherence. PATERNALISM The paternalism model is based on the expertise of the clini- cian, coupled with a grounding in beneficence (the doctor or healthcare professional knows what is best for the patient). This framework often conflicts with the concept of patient autonomy. This model is most acceptable in emergency situa- tions and to value-neutral, technical decisions. There has been a shift in healthcare in recent decades toward more patient- centered, autonomous decision making. THE RADICAL INDIVIDUALISM MODEL The patient has absolute autonomy and absolute rights over decisions regarding their body. The patient can assess alterna- tives, and healthcare staff members are obligated to adhere with these wishes. THE CONSUMER MODEL This relationship model is market based. Healthcare is seen as a commodity with the patient as a consumer. This relationship model tends to undermine the caregiver ethos by encouraging emotional disengagement. SHARED DECISION-MAKING MODEL Also known as the reciprocal model or negotiated contract model, the shared decision-making model lies between the extremes of paternalism and radical individualism. It is rooted in the concept of shared humanity in all participants. It emphasizes the relationship to the patient, not the disease. Holistic healthcare professionals, understanding the experi- ence from their perspective, work with the patient. They recognize that the burden of responsibility for the ultimate decision and change belongs with the patient. The healthcare professional’s duty is to educate and empower the patient.
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