Kim’s Blog: One of the Worst-Ever Days of My Career… and Advocating for Patients

by Kimberly Spering, MSN, FNP-BC

Think about the worst-ever day of your career. Do you have one? Can you recount, in excruciating detail, the episode that you ranked as your “worst-ever?” I’ve had a few… but this experience rates in the top-3 of all time.

My day started as any other routine day…but I paused when I reviewed the chart of a younger male, Spanish-only speaking dementia patient.

He had seen his PCP earlier this week, where his wife recounted that he had increased agitation, hitting her in the head so hard, that she had chronic headaches (and likely a concussion).

His wife had recounted to me that he refused to wash, refused to clean up after using the bathroom, and the only way she could make him change his clothes was to cut them off.

She shared a long history of their decades of married life. His dementia worsened several years ago, but significantly so in the past six months.

At my last visit, he became significantly agitated when I took his blood pressure. He paced non-stop; I assessed his heart rate and lung sounds while he walked. He hit me when I tried to check his temperature, pulse, and oximetry. As a result, I gave up on his assessment.

Today, I came to his home to find him asleep – for about 5 minutes.

His wife admitted that he started to hit her, even when she didn’t try to provide skin care or clean him up. This was a change from his baseline, where he would only become agitated with his wife trying to do personal care.

His risperidone had run out several weeks prior to my visit. His wife felt it caused lower extremity edema, so she did not restart it — and the edema improved. His PCP started him on low-dose Seroquel for his agitation about one week before my visit.

His wife flatly said, “he’s much worse now.”

I recognized signs of violence today. He was pacing, staring and swearing at me in Spanish. I asked his wife what he was saying, via an iPad Spanish interpreter. She wouldn’t tell me. I chose to focus on his wife and not engage him, as it made him worse. I found out later that he was threatening me in Spanish.

His wife admitted to being very afraid of him. After all, he hit her before, and he could not be reasoned with.

Desperately, I contacted our office social worker. She recommended that we call Protective Services.

Well…that person told me to call 911 and the police.

So, after doing so, stressing that the patient was acting erratically, threatening us, and that I was concerned about our safety…the first officer arrived 20 minutes later. Meanwhile, all of the preventative measures that our safety officers had discussed about our safety in the home was foremost in my mind.

And the officer? Well, he he was oh-so-angry at this call he was forced to take.

I explained the scenario. Oh, and remember, the patient/family was ONLY Spanish-speaking, which I mentioned to the dispatcher.

He rolled his eyes and scowled at me. “You should have called Crisis Intervention.”

I explained, through my gritted teeth, that I had done so, and only called 911 at their request. It didn’t matter. With a furrowed brow and muttered words under his breath, he radioed into his precinct, looking for an officer that spoke Spanish. He then informed me that, “no one working today speaks Spanish.”

Um, OK. I use an iPad for my Spanish-speaking patients. It’s required in health care. He refused to use my medical interpreter, who was still online from our earlier encounter. Finally, he reached one of the police department secretaries who spoke Spanish, who was instructed to talk to the patient. I reiterated that he had dementia and no ability to communicate. It didn’t matter; he told her to talk to him.

After many failed attempts, along with my pleading to have his person speak to the patient’s wife, he finally told the office person to speak to her. She clarified the issues, and agreed to complete his involuntary commitment admission paperwork. The patient’s daughter arrived, speaking some English, and the officer requested that she convey he needed to go to the hospital. She did. The patient balked. The officers walked him outside, then determined that he needed handcuffs to take him to the hospital… “for his safety.”

And let’s not overlook the nosy neighbors, congregating in their yard, noticing his predicament.

So let’s look at the global picture here.

1. Spanish-only speaking male with advanced dementia
2. Patient hitting his wife at random, argumentative, and a risk to himself/others
3. Heightened safety issues in the home…and a police force that took 20 minutes to respond to my call for a critical situation
4. A police officer who appeared to refuse to communicate with a Spanish-speaking family, until this NP insisted repeatedly that this happen
5. Need for medication management and placement in a long-term facility – which could only occur in the inpatient setting
6. Significant family trauma, as they witnessed their loved one being hauled off in handcuffs to the hospital

I think, without a doubt, this was one of the hardest issues I’ve felt in 27-plus years of nursing/NP practice. The grandson threw himself down in the yard, wailing. His wife sobbed non-stop, watching her husband being carted away like a criminal. And, let’s remember, he has Alzheimer’s Disease dementia with agitation.

He is not a criminal. He is not a derelict. He is not an “illegal immigrant.” Oh, but he just-so-happens to be Spanish-only speaking in a county that is predominantly Caucasian. And…oh yes, he has a NP who is a fighter and advocates for folks like him.

There HAS to be a better way to manage these situations.

A way without using restraints.

Not handcuffing folks who don’t have the ability to understand what is happening. Handcuffing patients should be an absolute LAST resort – not one that is convenient. And frankly, it will agitate dementia patients more if handcuffed.

Increasing education to our law enforcement about treating folks with dignity. These patients don’t understand, nor control their reactions. That doesn’t mean that they should be treated with harshness or lack of understanding.

Let’s imagine, if you will, having a relative with advanced dementia. One who is acting out more, being argumentative, resisting care. Would YOU like your loved one to be arrested and hauled away? Or would you advocate for those in the first response team to use compassion and try to understand the issues?

I’d bet, you would want the latter option.

It is our responsibility to advocate for these patients. Support their needs in declining cognitive function. Be their support when times get tough. Figure out ways to make life easier for them.

Wouldn’t we all want the same? Think about it.

Kim Spering has been a nurse for over 25 years and worked as an NP over the past 15 years in Family Medicine, Women’s Health, Internal Medicine, and now Palliative Medicine. She serves as an editorial board member of Clinician 1 and submit blogs to the website, with a goal of highlighting both the clinician and patient experience in health care.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.