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“Pain in the Neck” A Challenge or a Headache

“Pain in the Neck” A Challenge or a Headache. Youcef Sennour, M.D. Jerrlyn Jones, NP, MSN IDND August 22, 2006. Objectives. Present a real hospital case Outline challenges to discuss Obtain input and feedback about the challenges Open discussion. Clinical Case.

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“Pain in the Neck” A Challenge or a Headache

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  1. “Pain in the Neck”A Challenge or a Headache Youcef Sennour, M.D. Jerrlyn Jones, NP, MSN IDND August 22, 2006

  2. Objectives • Present a real hospital case • Outline challenges to discuss • Obtain input and feedback about the challenges • Open discussion

  3. Clinical Case • Dorothy is an 86-year-old white female admitted from home with COPD exacerbation (multiple admissions) • Evaluated by ACE for cognitive deficit and stubbornness! • Refuses medications, difficult to deal with, just wants to go home

  4. Social / Medical History • Widowed for 15 years • Lives in a condo for 1 year with her dog • Daughter (POA) lives next door • Other daughter busy caring for grand child

  5. Social / Medical History • Smokes and lies about it (refuses oxygen) • Drinks Vodka on a daily basis • Receives home health care, but ……. ”Whatever you say ma’am” • Daughters show concerns about her living situation but are helpless (patient is too controlling)

  6. Social / Medical History • Neuropsych testing: Cognitive and mood issues mostly ETOH related • Our assessment . Early Dementia . Anxiety with fear or loss of independence / Denial . Deconditioning . Caregiver concerns (no stress yet!)

  7. Social / Medical History • Our plan . Treat COPD exacerbation / Pneumonia . Prevent functional decline in hospital . Precautions for ETOH Withdrawal . Prevent Delirium . Family Conference: Discharge to rehab and look into a structured living environment

  8. Challenge • Refuses rehab or any other living situation alternative • Wants to go back home: Smoke and drink • Denial regarding identified issues “I am OK!” • “Does not want to give up the driver’s seat!”

  9. So! • How do you deal with a stubborn patient who is cognitively impaired but not severely demented? . Fire her and let it be someone else’s problem (including family) . Let her drive the bus!!! Since that’s what she wants . Work with her and deal with the headache . “To lie or not to lie” about the care plan!

  10. Dealing with stressful patients is difficult Dealing with difficult patients is stressful

  11. Thoughts generated by the Consultancy Group • Patient still has some capacity to make decisions. Should you let her make her own bad decisions and deal with the consequences? • Courts would not find her incompetent. Daughter cannot legally make decisions for patient. Patient is very intelligent and knows how to get her way and will continue to do this. • Address who is buying her alcohol and have them realize they are enabling her problem. Must make patient aware that her habits are jeopardizing her ability to stay at home. If she complies with the nebulizer treatments, she would more likely be able to stay home and not go to therapy. • Patient wants to die at home. Line up activities to get her what she wants, maybe drop her alcohol by a drink or two a day instead of asking her to completely quit. You won’t be able to get her to give up her habits. • Make her quality of life as good as they can for her. Educate her on the fact that she doesn’t want to die by suffocation from the COPD. • Hopefully she is not a danger to others. If she accepts oxygen, make sure she will not smoke while on it. • Work with family and get them to be less passive. Find out who is getting the alcohol and cigarettes, have them stop buying it for her.

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