A Dangerous Patient
Sooner or later, everyone comes in contact with a patient who swings at her, attempts to bite or scratch or spits. It goes with the territory, especially if you work with patients who have brain injury or Alzheimer's disease. We console ourselves with the thought that the patient doesn't really mean to do it. It's simply a reaction to fear or pain.
What if that isn't the case? What if the patient is doing it deliberately and with family encouragement? We have one like that. She is an older woman with moderate dementia. She doesn't want to be in a SNF. Her family doesn't want to take care of her at home. She is obese, manipulative and capable of more than she lets on. She constantly complaints to anyone, including her family, that she is being forced to do things she doesn't want to do.
Instead of encouraging her to cooperate, a daughter told her it was okay to fight back. She was overheard telling the patient that hitting and scratching were acceptable if the staff did something she didn't like. Things the patient doesn't like include being rolled in bed, getting up for meals, taking medicines and bathing. Yes, patients have the right to refuse. They have the right to say no to all of the above. They don't have the right to injure another person in the process.
Thus we have a gray area. On one hand, rolling, eating and bathing are necessary for good health. Medicines are necessary to combat her multiple co-morbidities. On the other hand, she has the right to not want them. The problem is she may not understand what she is refusing or the complications of those refusals. Is a demented person capable of making those decisions?
Now the problem has become how to care for this patient safely. Fortunately she isn't on therapy caseload. Had she behaved that way with me, I would have discharged after two warnings and notifying the family. She is coherent enough to understand her daughter's instructions. She is coherent enough to know better.