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Coping with not coping, or, “Yes, it sucks being hospitalized!”

March 3, 2013

I…. I guess there is a book!

Lately I’ve had a number of requests from nurses regarding hospital patients that I think fall under the same category. Maybe my perspective is off? I really have a hard time when I’m asked to medicate someone because they are having what appear to be normal emotions in response to hospitalization/new illness diagnosis. I understand where the nurse is coming from, but I also know a pill will not solve the issue.

I have been lucky to be working with some really skilled nurses. They are observant, they are strong advocates for their patients, and they also come to me with the situation, ideas for improving it, and are open-minded to hearing my thoughts. I try to be but I’m not always open-minded to theirs – in one category particularly.

There has been a cluster lately of requests for medication to help calm patients down. We do this all the time for people who struggle with chronic anxiety or panic disorder or are in acute psychosis. We use behavioural techniques and medications to help them feel more in control and give their brains a chance to tackle the difficult things they face. We also use environmental modification, re-orientation, chemical, and physical restraints (if absolutely necessary) for patients who are delirious.

In cases of delirium, behavioural methods and chemicals (anti-psychotics) are used to help prevent someone from hurting themselves (i.e. climbing over the bedrails, falling and breaking a hip) or hurting someone else  with violent/aggressive behaviour. It’s not ideal, but managing the behaviour gives the body time to recover from the underlying cause (infection, metabolic derangement, medication effect, new structural changes to the brain, etc.). Often it is a sweet, pleasantly demented old lady who gets a bladder infection and suddenly becomes not herself, confused, scared, disoriented, and striking out physically at those providing care.

It’s a terrible thing for the patient, for the family, and for the health providers. We are learning to become experts at preventing and managing delirium but it’s still a factor in many geriatric hospitalizations.

Now, I’m talking about something different. When a person is not delirious, their brain is working, they know who they are, where they are, why they are in hospital, and they want to leave or are “anxious.” They are afraid to leave their wife or kids or parent or dog alone at home, even if someone else is helping look after things at home. They are afraid to acquire a new illness in hospital. They miss their food. They hate the hospital bed. These people are often stubborn, frustrated, and have big hearts that are stretched because they can’t physically be available to those that need them, or they simply miss things at home. They can leave hospital against medical advice if we think they are of ‘sound’ (competent) mind. They might get worked up, find themselves at the nursing station, asking “when is the doctor coming?” “when is my test?” etc.

Lately, I’ve seen quite an increase in requests to give these patients “a little ativan” or “a little something to calm them down.” What am I being asked to medicate? Some people hate being in hospital. Everyone is at least a little bit stressed about being there, unless they are too sick to even notice or care, in which case they don’t have the energy to contemplate going home anyway. It would be ABNORMAL to want to be in hospital. People get better in hospital, but also bad things happen there. It’s loud and crowded and the food sucks and there’s no where for family to stay and you have to wear embarrassing gowns and get needled and so on. It’s NORMAL to not want to be in hospital. Right?

Yeah it’s not Canada. But that’s a lot of drugs!

So what shall I medicate? Chances are if I give “just a little ativan” I’ll make this persons fears come true: more complications in hospital, side effects of medication, etc. Moreover I’ll be suppressing their normal, appropriate reaction to, yes, a really stressful and uncomfortable situation. Plus the effect is temporary and doesn’t solve the underlying problem. And if they really don’t think they should be there, they can leave.

We can always use our words to reassure but when I have 26 inpatients in a day and 8 hrs to see them all (and we’re meant to spend 30min/patient), it’s hard to keep going back to hold the hand of someone who is scared. Fortunately, the same nurses who wonder if we could try a little medication are the most empathetic of the lot and their words are kind and reassuring to patients. But it’s hard for them to find the time too! They are even busier than the doctors. They have too many patients and too little time to bring them medications, start IVs, put in catheters, rub backs, bathe, teach, assess, measure vitals, help in-and-out of bed, answer calls from the family, etc. In the middle of the night when a patient is just plain upset, it would be nice to have a magic pill to help them feel better.

Sadly, there is no magic pill. The nurses are not wrong in their request, these patients definitely need something to help them, it’s just nothing that is contained in a medication. Part of health is developing a healthy coping style and some patients have this already; laughter is a pretty good place to go. I’m not afraid to be colloquial with patients, saying things like “It sucks!” or “I know you are frustrated! And you sure are stubborn!” and usually there is a laugh, a response at being understood, acknowledged but also in acceptance of the fact that we can’t solve everything at once. I try to help them with the coping as best I can and often ask patience of patients. “It’s the weekend and uh, unfortunately, nothing really happens around here on the weekend! Even the food is worse on the weekends!”

There’s probably more for me to learn about teaching someone the skills they need to cope, but I thought about what I naturally do to help people managed and it seems my mainstays are:

  1. explaining things so they understand what is happening, what to expect
  2. acknowledging how they feel, and sharing my empathy which I usually have because it’s easy to see that people are (rightfully) ‘stressed out,’ and I know I would be too in their shoes
  3. asking what we can do differently or what would help them feel more comfortable – sometimes it’s simple things like removing an IV, getting a bath, or having their family bring in warm socks
  4. having a laugh because yes, being in hospital is a kind of shitty thing to have happen for most people (sometimes swearing helps too… yep. select patients only!)

    and if all else fails and I can’t convince them:
  5. letting them know that I would like them to stay but they are free to sign themselves our “against medical advice” (AMA) if they feel strongly against the idea of remaining in hospital. This helps them know that they have options, and even if they don’t choose to leave AMA, perhaps bringing it up as an option gives them back some of the control they feel they have lost by being hospitalized.

After that, gee, I don’t know. I guess at that point, I would like a magic pill for making me feel better when I have failed to help someone. Or tips. Tips at how to help people cope, those will probably work better anyway 😉

3 Comments leave one →
  1. March 3, 2013 2:07 am

    Stick to your notions Jessica. But sometimes medications are helpful calm acute psychoses in dementia. Sleep is important to calm stress the next day, so sedation at bedtime may help you the nurses and patient rest. I don’t like chemical restraint to treat the nurses though. Also, sometimes pain is the problem.

  2. March 3, 2013 11:51 pm

    There are plenty of non-chemical coping skills for anxiety. It would be great if nurses and doctors were more conversant with these tools and shared them with patients so they could apply self-soothing techniques.

    For example, skills from Dialectical Behaviour Therapy are used for self-soothing. DBT is designed for BPD but skills like self-soothing are useful for anyone experiencing stress.

    There are also many excellent guided meditation audio products and apps, some a little too new agey but some are very solid tools based on proven methods like Progressive Muscle Relaxation and mindfulness meditation. Although hospitals may not have the technology to let everyone use iPads and mp3 players, just making patients aware of these options is empowering, and family can bring in mp3 players loaded up with recommended audio and video tools.

    A nurse who is skilled in Progressive Muscle Relaxation can also teach the technique to a patient quite quickly, without having to rely on audio or materials. Or you could photocopy a pamphlet to distribute.

    I applaud your decision not to medicate normal anxiety, and encourage you to help patients learn to manage it themselves.

    • March 4, 2013 10:22 pm

      thanks for the link –

      So many times patients have said they feel “better” knowing what is going on. I do try to focus on the positives, like “we are heading in the right direction; you’ve had a set back with this new pneumonia, but your x y and z are much better now, you’re up walking,” etc.

      That goes a long way but I do need to broaden my toolkit for the ‘I can’t solve it, some things suck, and you’re going to have to cope with it’ instances. I like some of the mindfulness-based CBT stuff and a I do that with anxiety patients often but it hard to teach in a noisy hospital with little time and especially to demented (not delirious) patients who won’t remember the instructions the next day anyhow. Handouts are a good idea; I use them in clinic all the time but rarely in hospital, perhaps I’ll print a few. Thanks for the suggestion.

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