Monday, April 28, 2008

Too hot to handle

There are very few nursing homes that will accept patients who have "behavior problems," which is a real shame, because there are lots of medical conditions that can disrupt people's behavior in ways that are beyond their control and that make them very tough to care for. I have seen some patients with medical problems that make them "disinhibited" sexually such that they can be offensive or even assaultive to caregiving staff. Once in field placement I was visiting at a care center and such a patient was escalating into agitation. I was able to keep him somewhat calm by wheeling him in his wheelchair round and round (and round) the facility but eventually I had to take him back to his room, where he thought it would be a grand idea if I joined him in bed. He grabbed me to implement his idea. I disengaged myself pretty easily and left him to (hopefully) calm down by being quiet in his room. I let staff know about his behavior, and they sighed wearily. The patient started shouting and cussing. The staff decided that it might be best not to respond, so as not to reinforce his behavior. (I was thinking more in terms of massive doses of antipsychotics but those were apparently not ordered for him, at least not that day!) "Just ignore him," the charge nurse told a young female CNA, who was cutting another patient's hair out in the hallway. I was charting in a corner behind the nurse's station. Aside from the screaming and cursing the environment was peaceful--that is, until the CNA let out a bloodcurdling shriek. The agitated patient had crawled out of his room and sneaked up behind her and stuck a hand up her shirt! "Didn't you see him coming?" one of the nurses asked. "YOU TOLD ME TO IGNORE HIM," shrieked the CNA. The patient, with a satisfied glimmer in his eye, was "escorted" back to his room by two security guards. The charge nurse brought the CNA back behind the nurse's station to have a break and file an incident report. The CNA seemed pretty shaken. Thinking to console her I said, "I know, it's a drag, but it's not your fault, after all he tried to haul me into his bed a while ago." "OH MY GOD," wailed the CNA, "HE TRIED TO HAUL THE CHAPLAIN INTO BED WITH HIM." The charge nurse said, tongue firmly in cheek, "He must have really wanted to get closer to God." I really had to laugh then. Wouldn't he have been in for a surprise? He was at least nominally Catholic, and in the Catholicism of my family upbringing, bedding a Protestant would have been a ticket to the hot place even if he HADN'T been married already. The care center staff were about fed up with the patient; I phoned his primary hospice nurse, who began ripping HER hair out by the fistful, and the last I heard, the poor fellow was on his way up to a more controlled unit with a behavior management focus, and the hospice provider's medical director was receiving an urgent request for some serious medication. I have to say, I was grateful for the time spent in an inner city church, where persons with behavioral issues are not at all uncommon. It really helps to have a context for separating the patient to some degree from the behavior, realizing that the offensive behavior is really NOT personally directed, and finding the humor in it all.


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