Combativeness

From the things you are saying, I agree with you. Our daughter working in a nursing home, and she got hit,bit, and slapped by the residents. I give you so much credit for doing what you do and keeping your family going strong. Love,Teko

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I've thought of two patients this past week, and you've written about both of them!

I was doing home health - this experience is from very early on in my career, my first home health post.  I received orders to evaluate and treat a patient with advanced AIDS.  He was young and already in a wheelchair from the toll the HIV had taken on his body.  

This was in the late-80's, still fairly early in the process of healthcare's understanding of this virus.   This man was young and angry, having to bear the scorn of many.  Those who had taken an oath to heal were inflicting more pain and suffering than they were healing.

As a result, he lashed out with the most potent weapon in his arsenal: bodily fluids.  (Remember, this was the 1980's.)  He was going to dialysis and had the entire team petrified.  He'd spit on everyone of them everytime he went in.  As a result, we looked like a hazmat team when we treated him.  Our appearance immediately put us at arms length.  

There are those patients who are cognitively impaired and do not realize what they are doing.  I'm not speaking to those here.  I'm also not talking about those with psychological diagnoses that cause them to harm others without regard for humanity.

This is for patients who are cognitively aware and able to make informed decisions and posess the ability to empathize.  As amazing to me as this is, there are those in this category, like this HIV/AIDS patient, who will intentionallly harm others who are trying to help them.  Almost always that comes from a deep place of distrust, usually because they are accustomed to receiving pain.  So they give pain first.  

It doesn't always work, but I found the best approach was to be direct.  I told this young man I knew of his reputation.  I knew of the stereotype that was out there and could only imagine how some had treated him.  I told him I was there to help him, not judge him.  I asked him to give me a chance to show him I was different.  I told him I would treat him with respect and compassion, but the first time he spit on me would be the last time he would see me.  I wasn't willing to be treated abusively by him or anyone else.  He never spit on me.  

I was lucky.  I had a supervisor whose philosophy was that we were to provide the best care we could, but we never had to put ourselves at physical risk to do that.  We were always free to reschedule an evaluation or treatment if we got to a neighborhood and felt unsafe.  A few homes we would routinely see with another discipline as a safeguard.  From time to time we would have to get a police escort.  Rarely did we have to decline to see the patient because of their environment, but it did happen.

Just as the patient has the right to decline therapy, in cases where there is undue physical risk to the therapist, that therapist should have the right to refuse therapy to that client.

Jason, have a look at NHS policy on aggressive behaviour aimed at all staff: http://www.hse.gov.uk/healthservices/violence/index.htm

Cheers, Dean