Patients who refuse to leave

[anon-y-mouse]

Does anyone have any advice convincing known hypochondriacs who "have pain" to leave the hospital, even after we've arranged outpatient followup for them? Unfortunately one of my patients is s/p CABGx2 10 years ago (and has a concomitant anxiety disorder I feel) and keeps checking in to the hospital with chest pain. Sadly with that kind of history, "boy who cried wolf" doesn't even apply and we obviously have to do all kinds of workups which are all negative and demonstrate great EF, etc. When it came time to discharging her (with outpatient followup), she was all like "can you please monitor me, I'm in pain and I can't move" etc., even though she had been going to the bathroom just fine the night before. I recommended to my resident that we give her 1mg Xanax (which she had already been receiving bid in the hospital) and coax her to move to a chair, then "transition" her out, but that has been such a herculean task so far. She has no other family, lives by herself, etc. and so it's reasonable to assume she'd be pretty lonely if we discharged her, which is probably why she wants to stay "just another day for monitoring". I would personally love to push IV "tough love" but something tells me that is not very professional. What has worked for other people in this situation? Getting a psych consult would take days, and this is something that can really be followed up on an outpatient basis. The patient is not sick and not about to die without our immediate monitoring and intervention. What to do?

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[sestamibi]

Just point and click.

 

[Law2Doc]

Pan it off on social work if they don't have someplace to go. If not, give the old "this is not a hotel" speech. Every resident has one you can borrow.

 

[Tired]

Tell your attending to man-up and give them the letter that says, "You have no medical reason to be here. Leave within 48hrs or you will incur the full cost of your stay."

 

[Samoa]

I've seen the "this is not a hotel" speech backfire horribly against residents. I would leave that to your attending.

Unfortunately, though, if your patient hasn't demonstrated (or won't) that she can get out of bed and walk a reasonable distance, you can't send her home. But there are a number of ways to handle this problem that won't generate letters to your hospital CEO about what a horrible uncaring doctor you are.

1. While I would stop short of saying it's not a hotel, if they're insured, you can certainly explain that their insurance company will stick them with the bill if they stay any longer than medically necessary. And you can certainly also explain that a hospital room is more expensive than a five star hotel. This way, you remain concerned about their welfare. You don't want them to have to pay.

2. Get social work involved.

3. Every floor has a nurse who's particularly good at dealing with these patients. Talk to the charge nurse, explain the situation, and get her assigned to your patient.

4. Get the patient to explain exactly what her fears are, in concrete terms, about going home. (i.e. Her: I don't think I can take care of myself. You: What are you afraid you won't be able to do?...if she's truly ready to go home, there should be easy answers to all of her concerns.)

5. Consult psychiatry if you fear that she may harm herself or sabotage her care in order to stay or be readmitted.

You really have to tag team these patients to get them to leave voluntarily, and not come right back to the ER. But at least if they do come back, you don't have to readmit them.

 

[MR1]

Multiple things work from my experience.

Agree with above - try and talk to them about it (the caring route), this has worked for me only a couple of times though.

Tell them about how it isn't medically necessary to stay and all that about insurance rushing to pay. I honestly have no idea if this works b\c every patient that didn't want to leave on me was "self pay"

My favorite in a situation like above is the bring up the dreaded "N" word - nursing home. If they can't take care of themselves, have no family to or the fam doesn't want to, and are medically stable - then guess where they go, a nursing home. Yeah I guess it is cold hearted in a way but in some situations it is the only thing that works

Lastly if all above fail, call your attending and like said above tell them to man or woman up... although I probably wouldn't use those exact words. In my experience when I have gotten to this point though, 90% of the time they don't man up and let them stay.

 

[edmadison]

Believe it or not, I've seen a few like this in pediatrics. Of course, they were borderline Munchausen's by Proxy cases. Our nurses simply told the family that they would be resposible for cleaning the room/changing the bed and that the parents were not allowed to leave with the child still there. Worked like a charm

Ed

 

[Ashers]

You really have to tag team these patients to get them to leave voluntarily, and not come right back to the ER. But at least if they do come back, you don't have to readmit them.

On medicine at the VA, we had about 3 people that we got out of the hospital who returned within a week (some within 2 days). The ED thought they needed to be readmitted, and so they were readmitted as a "bounce back." One person came back twice.

 

[elwademd]

i had a patient like that my 2nd year of residency.

i wrote the discharge orders, told the nurse the patient was to be discharged, spoke with the patient (self pay), and spoke with the social worker. i also spoke with the charge nurse i documented this (which is key).

once the nurse called me, i asked to speak with the charge nurse, whom i told the patient was medically stable for discharge with no acute issues, and that the hospital needed to figure out how to get the patient out. whether security needed to be called or the police was up to her.

security came, and escorted the patient to the taxi that the social worker arranged.




patient came back a few hours later to the emergency department. she kept hanging out in/near the ed (she was seen for some random complaint and not admitted, my hats off to the ed attending). i was eventually called by the ed director that "my patient" refused to leave. i told them she had been discharged, and that if she warranted admission i would be glad to do it, but if not to call the police and have her escorted off the premises or taken to jail.

she promptly left. and i never had her as a patient again.


long story short, if the patient's medically stable for discharge, put it on the hospital to figure out how to get the patient out of his/her room and to wherever they need to go.

 

[Samoa]

Believe it or not, I've seen a few like this in pediatrics. Of course, they were borderline Munchausen's by Proxy cases. Our nurses simply told the family that they would be resposible for cleaning the room/changing the bed and that the parents were not allowed to leave with the child still there. Worked like a charm

Ed

Yeah, I always wonder about that with parents who don't want their kids discharged. Seems like they always end up vomiting, or something else mysteriously happens to make it look like they need to stay.

I usually manage to get people out with the above steps. But then again I'm pretty good at laying down the law in a sympathetic manner.

And like MR1, my attendings always cave. In fact, they often pre-emptively tell us "if they don't want to go, they don't have to." Of course, it's not much extra work for THEM if their patients stay.

 

[Tired]

long story short, if the patient's medically stable for discharge, put it on the hospital to figure out how to get the patient out of his/her room and to wherever they need to go.

You're lucky. I've had a couple cases similar where the Social Worker sabotaged me, "Oh, the patient isn't comfortable to go home, and I support that." Then you're screwed.

 

[krikkrak]

We had a patient.. this really young woman. 19...G1P0....everyone thought she was malingering..kept complaining of pain and weakness on side of her body......they did an mri which showed nothing..everybody was ready to push her out....thought she was lying and just wanted a place to stay and get free meals...the woman ended up having a Schwanomma!! I know that pts truly do make up reasons to stay ....but this was just an example of where this woman was really telling the truth

 

[DaniMD]

ehh, nvm. deleted.

 

[elwademd]

You're lucky. I've had a couple cases similar where the Social Worker sabotaged me, "Oh, the patient isn't comfortable to go home, and I support that." Then you're screwed.

i have no problem being direct... some people call it being mean! lol. i would have stated that being uncomfortable going home is not a medical reason to stay in a hospital. the patient can have whatever reason(s) he/she wants to stay, but if there's no medical indication, there's no medical indication. or something to that effect.

the patient i described actually tried that, and the social worker seemed on the fence. i just stood my ground and said we had taken care of the medical problems (which i believe were diabetes out of control, and cellulitis), had arranged for free medications, a ride home... there was nothing else for me to do short of me taking her into my home, which wasn't about to happen!

We had a patient.. this really young woman. 19...G1P0....everyone thought she was malingering..kept complaining of pain and weakness on side of her body......they did an mri which showed nothing..everybody was ready to push her out....thought she was lying and just wanted a place to stay and get free meals...the woman ended up having a Schwanomma!! I know that pts truly do make up reasons to stay ....but this was just an example of where this woman was really telling the truth

your story needs a bit more detail, as the mri is the test of choice for a schwannoma, yet you say it was negative. what gives?

 

[Tired]

i have no problem being direct... some people call it being mean! lol. i would have stated that being uncomfortable going home is not a medical reason to stay in a hospital. the patient can have whatever reason(s) he/she wants to stay, but if there's no medical indication, there's no medical indication. or something to that effect.

??

Dude, where do you work that you take "comfortable going home" to literally mean "comfortable" as in free of pain and distress?

It's code for, "The patient does not believe that he/she will be able to get around independently and perform routine care of himself/herself out of the hospital." In other words, if they can't perform dressing changes, take meds, ambulate, perform ADLs ---> they're not suitable for discharge.

 

[PeepshowJohnny]

We had one who were "dying" but not in any particular hurry.

She had the usual stuff all obese 60 year olds have on a medicine service, CHF/HTN/PVD/DM/CRF/COPD etc. etc. Also about a year prior to this spell she got a CTthat showed a probable hepatocellular carcinoma. There was a note in the chart about her refusing further work up, etc.

Like I said, this ladies dying. She ain't going to make 5 years.

The problem is, at this time, she was actually quite "healthy" if she took her meds for CHF, wore her home oxygen, etc. I know because I saw how she was in the hospital when she was better.

The problem was she had a LOT of social problems with her family (don't want to get too specific) and some neighbors/church friends who would "Help her out" when she goes into the hospital. Very advantageous for her to get admitted. So it was convenient for her to load up on water, stop taking her lasix or raise/lower her blood sugar and get admitted. And each time she got "tuned up" it was like pulling teeth to get her out again because something always came up. She was the queen of bouncebacks. And of course, psych/social work were no help with this mess.

So when the hospital finally put the pressure on her (nursing home or hospice), she suddenly decides that NOW she wants her cancer worked up. However, the delay in her doing anything and being a poor functional status make all the consultants say "nothing we can do." It was really a sad case because you could see the desperation in her eyes as she tried to find any reason to stay in the hospital.

 

[roja]

The options you have depend on the institution and culture you practice in. Attendings who refuse to back you up not only undermine thier team, they reinforce the behavior. If you have great social workers, they can really help. If you have crappy ones, they can make your life miserable.

I see this on a regular basis in the ED. Thursday night, I had a woman who 'couldn't' walk from her arthritis pain. She refused all pain meds except toradol. She was driving the nurses bonkers and basically wanted ortho to come and inject her ankle with steroids. She kept throwing out the 'can't walk' bit. I refused to call ortho but told her we would make her an appt. Somehow when it came time for her 'bus' to leave, she all of a sudden got up and could walk.

I had another patient who was a paraplegic with a UTI who basically didn't want to leave because he couldn't sleep in his sweats and his home health aid was'nt there to 'tuck him in bed'. We talked to him and realized what was going on and when push came to shove, would have had him escorted home.

Many of these patients are testing limits. As a medical student or resident, its not really your job to put the final foot down. Get your attending. You don't make enough money to deal with this bs.

I like the nursing home bit though. That's a great idea.

 

[elwademd]

??

Dude, where do you work that you take "comfortable going home" to literally mean "comfortable" as in free of pain and distress?

It's code for, "The patient does not believe that he/she will be able to get around independently and perform routine care of himself/herself out of the hospital." In other words, if they can't perform dressing changes, take meds, ambulate, perform ADLs ---> they're not suitable for discharge.

after three years of residency, i've seen many different patient opinions on "comfortable to go home", some reasonable, some not so reasonable. there was one patient who refused to go home because she "wasn't comfortable". turns out, she didn't have central ac nor a window ac unit, just a fan, and it was summer. the nursing supervisor told her that our cafeteria was always a nice 74 degrees, and she could go there, but she would not be staying in the patient room.

i had another patient who told me he couldn't go home because he still had diabetes (was admitted for skin/soft tissue infection). mind you, this wasn't a new diagnosis, and he wasn't newly started on insulin therapy.

sometimes you ask a patient what's going on, and its a reasonable/legit uncomfortable. but i didn't think those were the patients we were talking about in this thread!

on the flip side, i had an elderly patient come in with some non specific abdominal complaints. if i remember correctly, it was constipation. but during the exam, i noticed ants on her person, and in her purse! i asked her if she noticed, and she said it was like that all the time, she couldn't get around the house much, and her grandson left her in her room, and didn't help her clean it much. however, she wanted to go home. i called the social worker, told her i wanted to file an aps report, and had her admitted for "diverticulitis". i'm not sure what happened to her, but i suspect that her grandson was taking her vicodin tabs and selling them on the street, in addition to neglecting her.

Attendings who refuse to back you up not only undermine thier team, they reinforce the behavior.

and piss off the team!

 

[MR1]

You're lucky. I've had a couple cases similar where the Social Worker sabotaged me, "Oh, the patient isn't comfortable to go home, and I support that." Then you're screwed.

Probably more that a spine-less attending, the SW's can really make or break your discharge. At my hospital it was very floor dependent, a couple of floors you were guarenteed an extra day or two b\c the SW were less than optimal. But the good ones, my first month of intern year I had this happen at about 5pm on a Friday, and when I asked the SW for help, they were literally like "Hell No", went in there said Dr MR1 says you are stable for d\c, here is your bus token, transport will be here in 2 minutes.

 

[krikkrak]

"your story needs a bit more detail, as the mri is the test of choice for a schwannoma, yet you say it was negative. what gives?[/quote]"

this wasnt my exact patient but in morning rounds we cover and take notes on all patients..her first mri came back just that ..negative..said they didnt see anything..which is why they were trying to push her out..she was pregnant..not sure what happened with her..she was transferred to another hospital after they realized she had a mass at C4 and C5

 

[krikkrak]

lol @ calling it "my story"..im a lurker on SDN ...just started to post..chill ...I dont have the time or desire to be a troll. I'm on rotation # 1 so i know I have a lot to learn..but it is worth noting that not every pt is not lying theiving and drug-seeking --which a lot of jaded residents and MSIVs seem to think. Perhaps Im not there yet (eye roll)

 

[elwademd]

"your story needs a bit more detail, as the mri is the test of choice for a schwannoma, yet you say it was negative. what gives?

"

this wasnt my exact patient but in morning rounds we cover and take notes on all patients..her first mri came back just that ..negative..said they didnt see anything..which is why they were trying to push her out..she was pregnant..not sure what happened with her..she was transferred to another hospital after they realized she had a mass at C4 and C5

lol @ calling it "my story"..im a lurker on SDN ...just started to post..chill ...I dont have the time or desire to be a troll. I'm on rotation # 1 so i know I have a lot to learn..but it is worth noting that not every pt is not lying theiving and drug-seeking --which a lot of jaded residents and MSIVs seem to think. Perhaps Im not there yet (eye roll)

i was just curious as to how the diagnosis came about. i wasn't trying to call you out/be mean/be negative.

as far as patients go, no, all are not liars, thieves, or drug seekers. but don't be naive and think that no patient will not be any of those! keep your guard up. you'll be surprised that as the further you go in your medical career, your "bs meter" will improve.

 

[angel80]

At my hospital, if none of the above mentioned tricks work, you call hospital administration. We have a number of physicians who have been hired for various administrative purposes. Part of their job is making sure that patients get out of the hospital when they are medically ready. They will make sure that the patient goes home. It's a big help if your attending is a wuss and doesn't want to take responsibility for sending the patient home. If insurance companies are going to stop reimbursing for nosocomial infections, DVTs, etc, then hospital administrators are going to start being your best friend when it comes to getting people out of the hospital sooner. When I was a medically student (at a different hospital), I remember a patient being evicted from the hospital (the hospital had to go to court and everything). It was completely ridiculous that it had to come to that.

 

[JaSam]

just put em on a high salt diet and water restrict them. They'll leave AMA in no time. Works everytime! Have a nice day kids.
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[DrJosephKim]

Stress the dangers of being in a hospital. Nosocomial infections can be deadly.

 

[DOme2009]

simple: make the pt npo and all meds per rectum

 

[anon-y-mouse]

Update: So my attending decided to be ULTRA lame and did not want to d/c this patient. Was not at all willing to write any sort of letter or anything because it was too 'mean'. Social work was lazy as usual and did nothing. And THEN, my patient decided that someone was 'out to get her' once she got out of the hospital, based on something random the cardiology fellow said. My intern thought she was crazy. My resident sort of disagreed, but at the same time acted somewhat incredulous/equivocal when seeing the patient again (and basically fed the patient's paranoia). My resident had apparently decided that the best way to get rid of this patient was to consult psych, play 'dumb' about cardiology fellow's errant comment... and then convinced the fresh psych intern to admit this patient to psychiatry for some sort of "anxiety disorder with paranoid features NOS" and somehow threw in the whole Xanax dependence thing. Tehee! I guess this situation played out like that rule in "House of God" about just shuffling people to other people's services.

 

[AmoryBlaine]

1. Daily PT/OT. If pt's are not able to move around they need to work on it. Malingerers hate physical therapists and esp if you get the PT on board with the plan they can make life hell.

2. Cardiac, low salt, ADA diets -- it's not a hotel.

3. See if you can get maintanence to d/c the TV.

4. Nursing home idea is brilliant.

5. Immediately cease all kindness/empathy towards patient. Refuse to discuss anything with them except the immediate plan of discharge.

6. Make your morning exams unpleasant. No more of the "intern point" auscultation here -- full neuro exams, make them walk, make them sit up, wake up etc etc.

 

[187502]

Get social service/a social worker involved, I always figured that's what they're there for.

 

[Tired]

1. Daily PT/OT. If pt's are not able to move around they need to work on it. Malingerers hate physical therapists and esp if you get the PT on board with the plan they can make life hell.

2. Cardiac, low salt, ADA diets -- it's not a hotel.

3. See if you can get maintanence to d/c the TV.

4. Nursing home idea is brilliant.

5. Immediately cease all kindness/empathy towards patient. Refuse to discuss anything with them except the immediate plan of discharge.

6. Make your morning exams unpleasant. No more of the "intern point" auscultation here -- full neuro exams, make them walk, make them sit up, wake up etc etc.

Those are good. Others that you might employ.

1) Stop all pain meds.

2) Turn up fluids to 2x maintenance so they have to pee all the time.

3) Come by while they're sleeping, and play with the thermostat.

4) Tell their nurse to "be careful" because the patient hates all members of their race (whatever race that nurse happens to be). Guarantees nursing retaliation.

5) The renal diet is the most unpleasant diet on the face of the earth.

6) Lactulose bid (unpleasant but not excessive)

7) Maintain two large-bore IVs at all times

8) Narcan is an anti-emetic, use liberally.