The Big “R”

The letter R may not hold much significance to some of you. To others, especially in the medical field, it’s a complete sentence.


This is a letter that I use constantly. I can drop an R on a MAR (medication administration record) faster than you can blink. In fact, if I had a penny (not a nickel, not a quarter, A PENNY) for every time I’ve charted refused on a patient, I’d be writing this blog from a yacht.

The elderly refuse treatment. It’s what they do, it’s their version of Fortnite.

Seems simple enough. Lesson learned. Information stored in your long-term memory and time to move on. Right?

Sorry. Much like life, obstinacy is rarely black and white.

Some friendly advice, that applies to anyone in your life and not just your failing loved one, never assume that someone is digging their heels in for the obvious reason.

Many times, they don’t even know why they’re digging their heels in.

Let me replay a conversation for you. An actual conversation. One that I have had some version of many times.

Patient: “I’m cold!”
(For the sake of expedience, I’ll leave the cursing out of the conversation. Rest assured, there are a lot of “hells” and “damns” getting thrown out during this. There are always a lot of hells and damns.)

Me: “I’ll grab you a blanket.”

P: “I don’t want a blanket!”

M: “What about another sweater?”

P: “I don’t want a sweater!”

M: “Would you like a snack?”
Random? Not really. This patient needs something, is demanding something, and just because she used the word “cold” doesn’t mean that is what she is feeling.

P: “I’m not hungry!”
Oh. Well… that wasn’t it.

M: I hand her a cup of water without saying a word. Why do I do this?
1-The obvious. Maybe she’s thirsty.
2-Maybe just holding something in her hand that requires a small level of focus             will calm her racing thoughts.
3-Maybe she’s just over stimulated and by responding to her verbally, I’m throwing her further into a tailspin.

P: She holds the cup, but does not drink and says nothing.
Have I gained or lost? I’ve gained. I’m not wearing the water, therefore, I’m getting closer.

M: Again, silently, I begin to wheel her into a new environment being intentional in my body language.

This is important.

Remember, as humans we are animals. In our youth, we rely heavily on our intellect and senses to process the world around us. As our understanding lessens and our senses become unreliable, our bodies return to those good ole’ animal instincts. The elderly can sense tension. They know when you’re rushed, annoyed, or at the end of your rope and they react to that as any animal does.

I position her right next to me as I return to my task of counting meds. This is a glaring example of my ridiculous courage. Her free hand could grasp my booty like a cobra, leaving me a bruise Rocky would envy.

After just a few seconds her body relaxes and she’s watching me. That’s when I break out my One-Woman show.

M: “Halloween was a few days ago. My daughter was Supergirl… blah blah blah… I ran out candy at my house… blah blah blah… My neighbors had a party…blah blah blah”
On and on I went with random, silly, tid-bits of my night. Slowly, as she listened to something she could remember experiencing herself, she wasn’t just relaxed, she became happy.

Did this patient refuse the blanket, sweater, and snack? No.

Once I gave her what she needed, she gladly accepted my offering.

Whatever she was feeling, that she had labeled “cold”, required 1:1 attention to cure. Once she got that, she was no longer cold.

I tell you this story to set a baseline. As a nurse, I am in no way rattled by refusals, non-compliance, or general tomfoolery.

As a daughter… Sigh!

The biggest non-compliance issue I have with my dad is him properly taking his Coumadin. (A blood thinner that prevents him from having a stroke.) This fight has been going on for years and I’m soooooo over it.

His Doctor and I have done everything from education to offering different solutions to solve this. Every bright idea we come up with either only lasts a few months or never gets any traction at all. I’m on the phone with his Cardiologist’s Coumadin nurse so often I may make her my kid’s emergency contact.

Her name is Michele. She seems delightful.

The problem is the issues my dad has with this drug are valid. They hold no weight when compared to a stroke, but to my dad, valid is valid.

A – Coumadin isn’t like Tylenol. There is no instant gratification when you take it. There is no relief from a disease that he can see or feel the symptoms of.
B – Coumadin is an old drug, like Moses took it old. This makes it cheap. Right up Big Jim’s alley. BUT it requires a monthly lab draw that costs money. This instantly throws it into the propaganda realm and, as already established, “That’s how they get ya!”
C – It’s a blood thinner. For those of you unfamiliar with the unavoidable side effects of blood thinners, let me give you a visual. My dad nicks himself shaving and his bathroom looks like Sparta.

Recently we were in our routine valley where he was refusing to get the lab draw to continue taking his Coumadin. I really felt like I was handling it like a mature adult. I very simply said, “Dad, do whatever you want.”

For the next two months, I believed I was coming to grips with the fact my dad would end up having a negative health event based on his refusals. Unfortunately, my behavior would later reveal I wasn’t so much coming to grips with it, as letting it fester.

I was sitting in a waiting room with my dad for an unrelated doctor’s appointment. It was very crowded causing my dad concern. I explained that not everyone was waiting for his doctor. Some were there for X-rays or labs.

“You know, like the Coumadin lab you should be getting.”

I shouldn’t have said it. It was petty. The nurse knew better, the daughter didn’t give a crap. I provoked him and his rebuttal was swift and predictable.

“Oh I know! You’re just like these doctors. Wanting me to waste my time and money!”

Now what I said next I’m not proud of. It’s not so much what I said, because it’s the truth, but how I said it. I was frustrated and my tone was harsh.

“Dad, I’m not worried about you dying from a stroke. I’m worried about you having a stroke and NOT dying! Have you considered what that would look like?!”

Yikes! The shame was instant.

Thankfully, his name was called ending our conversation. He never brought it up again and neither did I.

Shame started the race like the Hare in the classic story. Strong, a bullet right out of the gate. Right behind it was the tortoise of Grace. The shame petered out and Grace won. Grace always wins.

The next morning my dad got his lab draw. Without a lecture or a fight, he did it on his own.

For years my dad was refusing something and I wasn’t giving him what he needed. Proper motivation. I was using the avoidance of death to reason with him, knowing full well he’s not afraid to die. So much so, it’s a running joke in our family. He walks into every gathering announcing himself, “I’m here. I don’t know how!”

My dad does not feel he needs his life extended. Come to find out, he also does not need that daughter of his, who’s just like those doctors, having any more power over him while he’s here on earth.

Proper motivation. Check.

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