I'm caring for a 36-year-old patient who's been admitted for abdominal pain of unknown origin. A comprehensive clinical evaluation was negative for an underlying etiology of her pain. She has a history of depression but not substance abuse. Even so, her healthcare provider is skeptical about the reality of her pain. I suggested to the healthcare provider that she might benefit from a consultation with a pain management specialist, but he shot back, “Don't let her fool you. This is classic drug seeking behavior.” I was stunned. How should I have responded, and what can I do to advocate for my patient now?—P.V., IND.
The healthcare provider may have concerns about this patient's history of depression; if so, a psychiatric consult is warranted.
Ideally a pain management specialist could help your patient develop strategies to manage her pain. But as you know, abdominal pain has many potential causes, and pain can be sign of serious illness.
Perform a comprehensive pain assessment and health history, including information about any abdominal injuries, sexual activity, current medications (including over-the-counter products and herbal/dietary supplements), and pain patterns (such as those related to time of day, concurrent behaviors, and activities believed to cause or relieve the pain). With more information, you're in a better position to educate your patient about her options, including the option to seek a second opinion from a pain management specialist or other provider.
Failure to communicate
Recently I cared for an 81-year-old woman who was brought to the ED by her family after a fall. The patient was awake and alert, and initial testing ruled out stroke, cardiac dysrhythmias, and fractures. However, she complained of pain and was dehydrated, so the ED physician prescribed oral analgesia and I.V. fluids, and recommended that she be admitted for observation and further diagnostic studies. However, the patient refused treatment, repeatedly insisting that her family take her home. The physician and I both explained our concerns, but she refused to discuss it or even give her reasons for wanting to leave.
When I left the room, her family was arguing loudly with her, saying that they wouldn't drive her home because it wasn't safe for her to be alone. To make their point, they then left the hospital. Eventually a social worker and the physician agreed that she could make her own decisions and she was sent home via ambulance.
I was uncomfortable with the outcome but didn't know how to advocate for her when it was clear that she didn't want our help. What could I have done differently?—O.P., TEX.
So much about this situation and the patient's motivation is unknown because she was uncommunicative. What was her health history? Who was her primary healthcare provider, and was he or she contacted? Perhaps her family members weren't well informed. Perhaps she was a very private individual. What's most telling is the comment that “it wasn't safe for her to be alone at home.” Asking her family to elaborate on their concerns would have been helpful. Was she offered a home healthcare follow up? If not, you could have arranged a referral to the hospital's case manager to contact the patient after discharge, have a visiting nurse evaluate her home situation, and help her plan self-care strategies if needed.
It's difficult for nurses to form a bond of trust during a patient's brief time in the ED. In the future, you could advocate for a patient in this situation by simply looking for a single point of contact on which you could begin to build trust. Letting the patient know that you're here just to listen and that you'd like to get to know her and understand what's important to her might help to break through her defenses. In this case “offering self” may have been the most therapeutic nursing intervention available when the patient was adamantly refusing everything else.