When Your Hands Are Tied

“No, no Mr. Fisher.  You need to get back to your room!”

That’s what I hear as I round the corner with a fresh cup of coffee the other night.  I’m also greeted by an elderly man, droopy drawers and all, attempting to urinate on our new floor.  Yep, just another night.  But it isn’t.  I hear the voices start to rise, his more than the nurse and I can sense the frustration in her voice as she tries valiantly to both defuse the situation and return Mr. Fisher to his room, safely.  Normally, I’d be jumping in, but knowing Mr. Fisher, extra people running in to help only makes him ramp up more.  It riles him up something fierce.  I can see him though.  Slightly defensive posture, fists clenched, muttering gibberish and leaning back almost as if trying to figure out if he is going to strike.  Besides what we’re doing, there’s not a thing we can do.

You see, our hands have been tied by the family.  Instead of having medication available should Mr. Fisher get out of control, we have nothing.  Just us.  Luckily every time he ramps up, we’re able to bring him back down.  But it is getting worse.  On admit, the MDs prescribed some medications to help even his moods and reduce the paranoia and hallucinations,the psychosis of advanced dementia.  And you know what?  It was starting to work.  Now instead of walking down the hall with PT crapping his pants and being wildly inappropriate, he’s actually returning to regulated behaviors.  But no, the family decided they didn’t want that and of course the docs complied.  Gone is the Aricept, gone is the Seroquel, gone is the Zyprexa and Haldol for outbreaks of violent behavior.  In their place is an order to “call son if planning to give PRN meds”.  Gone is our ability to make decisions.  All we’re left with is our abilities to talk this gentleman down from the brink.

The very first night, he got crazy.  Between the nurse and I, we spent 2 hours trying to bring him back.  All for naught, until my friend Haldol.  Just a touch and he calmed down.  Evidently, the next day, the family threw a shit-fit over this.  And I’m left to wonder why.  It’s not like we had to call for a PRN order, the doc had written the Haldol as part of her admission orders.  It’s not like we hadn’t tried everything else at our disposal, believe me, we had.  In essence our hands were tied.  It pissed me off.  None of the family had any sort of medical background.  They didn’t want their dad “oversedated”.  I can understand that.  We have a tendency to chemically restrain folks for the sheer convince of it, but I’ve never been an advocate of that.  It is however a good thing to have available if the patient gets out of control.

As the days wore on, the therapeutic regimen of medications designed to temper some of the behaviors of dementia, like him taking a crap as he walked in the hall with PT, began to work.  He reverts back to the gentleman  we knew he probaly was.  Instaed of continuing, the family unilaterally decides that it isn’t the medication, but that he’s actually doing better.  So they insist the docs stop them.  All we have a touch of trazadone to help him sleep at night.  Thanks.

What really screwed us though, was that the off-going nurse actually said, “Oh yeah, he’s been an angel all day!”  That’s like saying “It’s awfully quiet!” at 2am.  Good things can never come of it.  And sure enough the worst began to happen.  He ramped up again and again.  The nurse would spend 2 hours talking him down and he would sleep for another couple of hours and then the process would start all over again.  In a moment of frustration I posit, “Maybe we should call the family.  Maybe they can get him to clean up.”  Yeah, right.  We were being used by the family as a respite from caring for him, but they were unwilling to give us the tools needed.  It’s like when you need to cut lumber and all you have is a plastic steak knife.

I know what the studies say about the use of atypical anti-psychotics and the geriatric population.  At times you have to balance the long and short-term goals.  Do we want our loved ones to be more lucid or more “natural’?  Is the risk worth the outcome?  The most frustrating part of this was that the family directed this, but they had no medical background at all.  Even though the physicians thoroughly explained why the medications should be used and for us to have in reserve they still wouldn’t let the professionals do their job.  I wonder what would have happened if we could not have gotten Mr. Fisher to calm down.  What would have they said if we had to restrain him?  What if he had gotten violent and hurt one of our nurses (an ex-lumberjack, he hadn’t lost his strength)?  Could the nurse have pressed charges against the family for denying them the tools to do their job right?  But lucky for us, we were able to soothe him and get him back to his room and bed.  What about next time?  When does it become the nurse’s, no the physician’s, responsibility to provide the neccessary tools to keep the patient and themselves safe?  And in this day and age of litigation, how much can/should the fmily direct care if it comes to a patient safety issue?

I don’t have any true answers to any of it.  I believe that we should have the tools needed, the gamut from interpersonal tools, to chemicals to restraints to use when needed to keep our patients and ourselves safe.  Maybe though, we should just sedate, intubate and paralyze every patient we get.  If I wanted that, I’d go to the ICU, but most days I like it when my patients can talk to me, even when they are acting out.