Transcript Pain in the neck

“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
 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
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
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)
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!)
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
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!”
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!
Dealing with stressful patients is difficult
Dealing with difficult patients is stressful
Thoughts generated by the Consultancy Group
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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.