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At the rehabilitation hospital where I work, a 17-year-old patient is constantly raising a ruckus. "Justin" was injured 7 months ago in a snowboarding accident and has quadriplegia. He's very demanding, calling other patients and staff insulting names and spitting at them. We've tried behavioral therapy and counseling, but the behaviors persist. One of Justin's relatives told us that before the accident, Justin was often in trouble at school.


Our other patients dislike having him around, and their families have complained to administration. Is it ethical for the hospital to terminate his care if his behavior doesn't improve?-D.E., ILL


All patients have rights that must be protected during hospitalization. Two of the most basic rights are to be cared for safely and to be cared for with respect. Any actions that jeopardize these rights are unethical.


Justin seems intent on doing everything within his power to create havoc-and the key words here are "within his power." After a spinal cord injury, patients struggle with behavior and control issues just like any other patient with a serious illness or injury.


Earlier in life, Justin learned that if he's bad enough, he'll get suspended or expelled from school. Perhaps he's hoping that his actions will get him "expelled" from the hospital too. Let him know that this ploy won't work here.


However negative, Justin's behavior suggests that he wants your attention. So don't give in to the temptation to minimize your time with him. Instead, show your concern by sitting down and asking him why he lashes out at others. In a firm but nonjudgmental tone, explain clearly that certain behavior isn't acceptable and set limits. Look for ways to return some control to him and to encourage better behavior with rewards or privileges that are meaningful to him.


Involve the staff, administration, counselors, and Justin's family, so everyone who cares for him responds to outbursts in the same clear, consistent way. At key points, include Justin in the process to encourage responsibility and accountability.


Finally, examine your own attitudes to make sure your nursing care is professional and respectful-regardless of Justin's behavior. Avoid labeling him with words such as "demanding"-not only in your documentation, but also in conversations with other caregivers.