What would you do???

[Missingyou]

Not what SHOULD you do, but what would you honestly do in this situation:

You work in a nursing home. You have an awesome hall partner (Jessica)who loves taking care of her residents and seems to really care about them...

One of her residents (Mary) has dementia and her family request her teeth be brushed 2x daily. Your hall partner(Jessica) asks you to help because she's a "fighter". The resident "Mary" refuses to have her teeth brushed as soon as she sees the toothbrush. Jessica proceeds to push the toothbrush into her mouth and Mary begins slapping Jessica and swearing. Jessica still continues, and Mary continues to punch, slap, cry, swear, etc....Jessica turns to you and tells you to hold Mary's hands down so she can continue, you tell her it isn't worth it, let Mary be, Jessica calmly insists that it be done as family requests.....

Right then and there, in that moment, what do you do???

[SoldierNurse22, BSN, RN]

And if Mary did not have dementia, she was of sound mind, but had a stroke and needed assistance, but refused to have her teeth brushed...whether or not she knew of the ill effects of not brushing??

or

what about the same scenerio only instead of tooth brushing, make it showering 2x a wk and she refuses everytime?

or

Having a BM in her brief and she refuses to be washed up??? (with or without dementia)

or

refusing to eat??

I think it's sometimes a fine line we, as CNA's, walk. Clearly, it's a health issue if she needs to be washed of BM, refusal or not.

But, Toothbrushing? showering?? EATING?? Can "forcing" them to do any of these things be viewed as abuse?, at the same time, can NOT getting them done be viewed as abuse too!?

When in doubt, ask the charge nurse what to do, but still, it depends on how long the refusal has been going on and what it is that they are refusing....still a fine line that frightens me....

All great questions. I'll try to take them as you present them:

1. Mary doesn't have dementia but she had a stroke and refuses to brush her teeth.

I'd start by trying to figure out why she doesn't want to brush her teeth. Is she embarrassed to accept assistance? Is she afraid of something? Is she depressed? Is her refusal due to a mental status change secondary to another condition, such as another stroke?

For a patient who is A&Ox3 and able to understand the need for personal hygiene, refusal to take care of oneself could be indicative of an underlying issue, such as depression, that needs to be addressed.

2. Mary refuses to shower x2 weeks.

Again, if Mary is A&Ox3 and refusing, I'd try to figure out why and assess for mental status changes. I've never forced a patient who is A&Ox3 to clean up, but I've also never had to.

3. Mary has a BM and refuses to be washed up.

Again, why? This is clearly a matter of immediate hygiene for not only the patient but for the nursing staff. I'd do all of the above as previously listed (assess for mental status changes, depression, etc) and go from there.

4. Mary is refusing to eat.

Well, you sure can't make her eat. Repeat all steps above and discuss a plan of care with the patient's physician. If the patient is at the end of their life, some patients will just stop eating, and there's nothing you can do to change that. If they're A&Ox3, that's their right and it's natural as the body declines to stop feeling hungry/thirsty.

Bottom line, if you're confused, talk to the patient and try to understand what's going on in their mind. If you're still confused, talk to the nursing staff about the problem. Perhaps they know something you don't or they know a good way to approach the issue.

[i_love_patient_care]

That is tough. She doesn't have a nurse or aide who know her well enough to tell you what works with her? Some people who have dementia have a better time of day that they are cooperative. Maybe try talking in a softer voice. Flat out saying refused isn't going to cut it with some family members. Maybe they can come in and say what has worked for them. That is tough. ((Big Hugs)) I hope it gets figured out soon for the Resident and your sake.

[Mewsin]

What happens if you give the toothbrush to Mary?

[imintrouble, BSN, RN]

I'd stop. I don't care about legal ramifications or POA outrage.

I don't care if the pt is confused or not. If an intervention requires me to restrain the pt/res It's going to have involve something life threatening.

Teeth brushing doesn't rise to my threshold of necessary treatments.

I'm a nurse. I know the importance of oral hygiene. I also know the psychological pain caused by being forcibly restrained and having unwanted whatever done to your body. Saying the person is confused just doesn't cut it. When shown the toothbrush she knew exactly what it was and that she didn't want it.

I'd chart refusal ad nauseam. Speak to the family, and make them watch.

If they continued to demand it be done, I'd very politely insist THEY try it.

[schnookimz]

I'd stop. I don't care about legal ramifications or POA outrage. I don't care if the pt is confused or not. If an intervention requires me to restrain the pt/res It's going to have involve something life threatening. Teeth brushing doesn't rise to my threshold of necessary treatments. I'm a nurse. I know the importance of oral hygiene. I also know the psychological pain caused by being forcibly restrained and having unwanted whatever done to your body. Saying the person is confused just doesn't cut it. When shown the toothbrush she knew exactly what it was and that she didn't want it. I'd chart refusal ad nauseam. Speak to the family and make them watch. If they continued to demand it be done, I'd very politely insist THEY try it.[/quote']

How do you know she knows what a toothbrush is??? She's confused, we can't read her mind.

And it may become life threatening if it ruins her teeth and she can't eat or she gets so germy that she gets pneumonia or she has infected sores in her mouth that we don't know about bc no one bothers to look in there anymore.

[imintrouble, BSN, RN]

How do you know she knows what a toothbrush is??? She's confused, we can't read her mind.

And it may become life threatening if it ruins her teeth and she can't eat or she gets so germy that she gets pneumonia or she has infected sores in her mouth that we don't know about bc no one bothers to look in there anymore.

It doesn't matter if she remembers what a tbrush is. It doesn't matter if she doesn't know it's for her own good. According to the OP, the resistance to the activity began as soon as she saw the tbrush. She might not have remembered what the object was for, but she didn't want it in her mouth. Maybe she connected the restraint and the pain with having her teeth brushed. Who knows?

As far as I'm concerned, in this situation, with this resident, with the described activity, she has the right to refuse. Germy teeth and all:yes:

[mvm2]

How do you know she knows what a toothbrush is??? She's confused, we can't read her mind.

And it may become life threatening if it ruins her teeth and she can't eat or she gets so germy that she gets pneumonia or she has infected sores in her mouth that we don't know about bc no one bothers to look in there anymore.

Wow I think you are taking this way out of the relm of what the OP was looking for when posting this. She is not asking if we think oral hygene is important or not. What she is asking is if you find yourself in this situation where you are seeing this aide pushing herself onto a dear old lady by force and asking YOU to help her are YOU going to participate in this, or are you going to be this ladies advicate and saying I will not be a part of this? As previous posters have stated there are other ways and options we can do to try to see that this important care is given. BUT there are also limits to what I am willing to do.

[Been there,done that, ASN, RN]

I would have the FAMILY come in and brush her teeth twice a day

[LoriRNCM, ADN, ASN, RN]

Maybe poor Mary has an abscessed tooth that needs to be looked at, or caries that hurts when you brush her teeth. I'd smack you if you came at me with a toothbrush when my mouth already hurts too.

[Compassion_x]

I would tell the aide that the resident has a right to refuse regardless of what her family wants. Wait until later, calm her down and sweet talk her a bit, THEN ask again to brush her teeth. Also tell the nurse what happened.

[Whispera, MSN, RN]

Does she talk? Does she answer questions? Ask her what's up.

You said she's not non-decisional. That means she has the right to refuse care, no matter what it is, unless there's a court order or establishment of her inability to make decisions for herself.

Restraining her is battery, as is forced tooth-brushing.

[slilly]

If I were you I would tell your hall partner Jessica to stop trying to brush Mary's teeth at the moment, because this is aggravating the resident, also for backup and for documenting purposes call the nurse or whoever is in charge for the shift in and let them see this and explain that Jessica was trying to do the task the family had requested. Let it be known that you did not lay hands on Mary either because if I would think that if you didn't mention that, it could come back later in a report against you, but I don't really know for sure. I personally have a lot of patients where I work that if they outright refuse the care I try to give them and its known on their chart they have dementia, then I go to my nurse and tell them they refused at this time, and I chart it, but also ask the nurse to see if she approach this patient and try to see if they will let me do their care. On the subject of the family request for this care to be done, how many times do they actually come in and see her? I am not trying to be nosy but where I work we get a lot of family requests and which most are followed through, but in some cases if they are never there and I know I have to try and do all the care needed on my patient and when they refuse it time and time after again, then I can't go against what my patient wants, my patient obviously still knows what is going on apparently, at least that is what I think in my head. So when family does come in and see the patient I do explain to them what has been going on and if the patient has refused what they have requested, and if they have an issue then they need to talk to the nurse or nurse manager, because I am doing what the patient wants. So my personal feeling on family requests is kinda mixed depending on the situation and the person. Hope that helps in any way!