No Wonder He's Being an Asshole

There is a reasonable explanation for everything

Sleeping in room 413 is my 73-year-old patient who is here for his second leg amputation and an infection of a wound on his butt. It’s 3:00 am, his mouth is wide open, the TV and the light are on, and he sits upright - directly on his wound despite anyone’s advice. Over his lap is his bedside table full of trash that he refuses to let anyone clean up.

He’s been belligerent and uncooperative his entire time here. He’s slapped or punched several nurses. He’s been pocketing his opioid pills in his mouth and saving them for later. He called me a bitch for reminding him to stay off his wound; it was so advanced that he couldn't even feel it anymore.

All my patients were finally asleep and it was time for my lunch break, so I gave a brief report to a coworker and before I could say anything about room 413 she said “I know him. I had him the other day. He’s such an asshole. I don’t know how people can treat nurses like that. Anyway, you’re good to go.” I nod silently before mentioning the pain medication he has ordered should he need it. I want to tell her that he’s probably not really an asshole, he’s just being an asshole, and that there’s probably a reasonable explanation for it. I hold my tongue because I don’t want to deal with any drama today.

The first half of today was too busy to read anything more than the basics so when I get back from break I open his chart and sigh as I catch up on his history:

Mother: drug overdose 45 y/o

Father: estranged

Brother: estranged

Sister: developmental disability - unspecified - pt primary caregiver

I scribble some notes before getting up to answer a call light and on my way back I peek in his room. I lean against the door and watch him under the fluorescent hospital light and try to imagine losing a mom to drugs as a young man, maybe having no father figure, an estranged sibling and a disabled one to take care of. One leg amputated, now two. He’s a Vietnam veteran so I’m sure he has debilitating PTSD and I assume he’s never gotten help for it. He’s of a generation where I genuinely wonder if he has ever cried without feeling embarrassed about it. I wonder how his sister has been cared for the last 2 months he’s been here. No wonder he’s being an asshole.

He must have sensed my presence and woke up, blurting out “get this fucking pillow out from under me.” I took a deep breath and donned my blue gown and gloves - he had an infection that was particularly contagious and warranted “isolation” and so staff needed to wear extra gear. As I entered I noticed his irritation at me putting the gown on and I told him “I hope you know the gown is just because your wound has a tough germ to treat. We just gotta make sure it doesn’t leave this room. I wish we didn’t have to wear them, either.” He seemed surprised and with the raspy voice of a worn-out old man said “oh, didn’t know that, I thought it was because I was gross.” When I put on gowns, I always wonder if the patient understands. You would think they do, but I know sometimes they don’t. I had a feeling he was one. It makes me sad to think this man has been here for 2 months and thought he was so gross the staff were putting on gowns and gloves to be near him. No wonder he’s being an asshole.

I told him to tell me if there was anything else he didn’t understand and for the next 45 minutes we talked about his illnesses and what the medical team was trying to do to treat them. I say trying because he was refusing most of the care we were attempting to provide. Wound care, IV antibiotics, physical therapy, medications for his blood pressure. On top of all that, he was barely eating.

I ask why he wasn’t trying to stay off his wound. He said it was too painful for his leg and it didn’t seem worth the trouble. It wasn’t until I showed him a photo of his wound that he understood. I ask why he wasn’t participating in physical therapy and he said because it was too painful. I told him we could pre-medicate him with pain medicine before therapy. I ask why he is pocketing his pills, and he says it helps him sleep to take more before bed. I told him we could ask the doctor about sleeping pills and to adjust his pain medicine, but he needs to promise to stop pocketing his pills because it puts him at risk for an overdose and the doctor isn’t going to give him more pain pills if he keeps it up. He asks why no one offered that to begin with. I say I don’t know, and that I can’t guarantee the doctor will do anything, but that I will ask, and that he is going to have to stop being so aggressive for staff to want to help him. Whether no one bothered to explain any of this to this patient or he just wasn’t willing to listen, I’m not sure. I do know that being sick and debilitated in the hospital is just about the most vulnerable situation for an old man to be in and that vulnerability, if not met with physical and psychological safety, is sure as hell going to make a person defensive, rude, and a terrible listener. An essential skill of this job is knowing how to bring a person’s guard down.

Recently I got lunch with a nurse who shared that what burns her out the most was mean patients. How can people be so unappreciative? I don’t get how people can be so mean, she said. I wish I responded more thoughtfully, I worry that I made her feel bad. I said really? That has never phased me, I don’t think my feelings have ever genuinely been hurt by a patient. Our conversation makes me think about why it doesn’t phase me when a patient calls me a bitch or kicks me or calls me an uglier than a monkey? (Yes, uglier than a monkey.)

Until a day comes that breaks the camel's back and I lose all patience; here is my philosophy: The ability to consider a person’s context before making assumptions about them creates resilience. When people are being aggressive, it is a response to something - how they are being treated, how they are not being treated. Untreated pain. Being misunderstood. It is about the personal issues that a person does not know how to deal with or the frustration that they don’t have the language for. Aggression (aside from the context of delirium) is an attempt to gain control or self-protect - so a winning strategy is to give people back their control and remind them that they are safe. We do this by being curious and trying to understand where they are coming from. By offering instead of telling. By treating them with dignity even when it seems that they don’t deserve it.

Understanding is not the same thing as agreement - but it is a prerequisite to compromise.

By the end of my shift he was shifting his own weight in bed to stay off his wound, he agreed to work with physical therapy first thing in the morning, took all of his medication, and he even finished a boost supplement.

He wasn’t an asshole. He was being an asshole. For a reason. It doesn’t justify the behavior - but it makes it understandable. When something is understandable, we can work with that.

As my shift wraps up I send a message to the oncoming physical therapist to check in with the nurse so she can premedicate our guy. I ask the doctor to discuss pain meds and a sleeping pill with the patient at rounds and that I think his pain is poorly controlled, and that I think it has to do with why he’s being so uncooperative. I remind my guy to try to be a little nicer to everyone and that he can’t be punching people. I add all of this to my nursing note. 7:00 am rolls around and I give report to the nurse who took care of him yesterday. She gives me the impression that if I try to give her a proper report she will roll her eyes as if I am wasting her time, so I just say “he really needs us to explain his care better, he didn’t really seem to understand anything that was going on. He took his meds and shifted his weight for me last night though, so yeah, just fyi.” She rolls her eyes and says “yeah it’s because he doesn’t fucking listen.”

As I’m leaving, I pass his room and overhear an interaction between him and the nurse: “What is this medicine for” “your doctor prescribed it” “what for” “for your wound” “but what does it do?” “It’s an antibiotic.” He grunts. The nurse throws away all of the trash on his table and he yells “I need that stuff! Don’t touch my fucking stuff!” she says “I only threw away the trash.”

No wonder.