Tough Love Can Be Tough: On Setting Boundaries with ‘Needy’ Patients

I’m used to patients being terrified of getting worse. But it took me awhile to realize that the main issue I was now dealing with was that this patient was terrified of getting better. I’m sure there are plenty of psychological publications and blog posts by some really smart people that have already covered this phenomenon, so I certainly don’t claim to be discovering anything new. But it was a new situation for me to find myself in, particularly as I had been with this patient for over a month and had a more intricate relationship with him than with patients that I have for only one or two days. There is an inherent emotional and psychological distance that you can keep from patients and families whom you care for for only a shift or two. But this changes, inevitably, when you are with them as their nurse for an extended period of time.

He had a physical disease process with some setbacks during his recovery, which sentenced him to a prolonged hospital stay. But he also had some psychological and emotional dysfunction that went even further back, which appeared to have gone unaddressed until now. He was intensely needy, refusing to let his primary caretaker from home rest, and fearfully reluctant to let go of various hospital treatments that had become his source of security over time. On the morning of my final shift with him, knowing that he would soon be transitioning out of the ICU, I started off the shift by saying, “Our big goal today is to work on boundaries.” His response: “What’s that?” Oh dear. Each step in this final push towards recovery meant that there would less of all the external support – less treatment, less comfort and coddling, less urgency of response for issues that were not true crises. The growing expectation on him to work through the uncomfortable changes and responsibilities of recovery was almost more than he could handle. I’m so used to my therapeutic nursing role being that of one who brings comfort and relief as much as possible. I wish someone had told me in nursing school that sometimes, the therapeutic nurse is also the one who will hold his or her ground with a firm ‘no’ when the patient is crying, pleading, throwing a tantrum, suffering (but not really suffering).

There is a big part of my ego that wanted him to love me as his primary nurse. I wanted him to thank me for everything I had helped him through. But my final shift with him involved me being a big source of his frustration and discomfort, perhaps some disappointment as well. There would be no thanks offered – just his desperate plea that I would somehow let him go back to the less healthy state that he was in before. It was at that point that I knew for certain I had truly given him the very best that I could as his nurse, and as his friend. Because more than wanting his thanks, I wanted him to get better.

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