[SassyRedhead]

I think you all are reading this incorrectly. I am not imposing my will on her. Frankly, I don't care if she eats the whole bag. This has nothing to do with a value system. Please, if you will, respond to the issue at hand, which is about nurses that arbitrarily follow a MD order. I tried to outline my thought process with the Vicodin example. I would appreciate response to that.

[rn/writer]

Nursing staff on my unit have been having a debate lately about where the line is with diabetic patients on MD-ordered ADA or carb control diets and patient rights. In particular, a diabetic pt on our unit had a big bag of candy in her belongings and went postal about being allowed to have it, even though she was ordered QID accuchecks with PO antidiabetic meds and sliding scale insulin.

When a doc orders an ADA diet for the patient, that generally refers to what is available for the patient from the hospital kitchen, what kind of meals the dietary staff will send up. I don't know how far that order extends beyond the kitchen.

I think you are right to be concerned about doing something that directly contradicts the doc's expressed desire that the patient be on a specific diet. To a point. If the patient were hungry, you would probably try to find a snack that wouldn't be off the charts. But that's where the gray area begins.

What if the patient wanted three packages of cookies? Or toast and double packets of jelly? I guess the real question is where do doctor's orders leave off and patient rights begin and how do you not get caught in the middle, especially in a situation where visitors are not around, and the patient needs you to help her get what she wants. I don't have any easy answers.

You might want to discuss this with your manager, as well as with someone from risk management to formulate some kind of staff policy so that your choices are covered either under the doc's orders or under the patient's rights. This shouldn't be a "darned if you do" and "darned if you don't" scenario. It's important to determine ahead of time whose "law" is trump? The docs need to be made aware of whatever is decided, too.

As for the example of the Vicodin, there is a legal difference between a substance which is controlled for everyone and candy which is legal and has no restrictions save for the arbitrary ones created by the doc.

In the case you mentioned, would it have been possible to bring the woman's purse or suitcase to the bed so that she could have been the "guilty party" in getting the candy? I know, that probably still seems like enabling, but what good does it do to focus so strongly on the power struggle. If you merely place her belongings within reach, you are not the one making the choice.

You mentioned having many therapeutic conversations with her. I do NOT mean to criticize or negate your efforts by any means, but I would like to suggest that in many instances, what is thought to be therapeutic by the caregivers is not perceived that same way by the patient.

Does the candy mean anything to her besides the obvious?

I do want to acknowledge your reference to the fact that this patient has psych issues along with her physical problems. I worked in psych for many years and see a large overlap between psych issues and diabetic issues. Both populations are historically beleaguered by having decisions made for them and treatments forced upon them. Both have lost control in a deep and drastic manner. And each has a tendency to become suspicious and defiant in the name of retaining autonomy.

You definitely have your work cut out for you. I would say that having a good policy and procedure in place for this kind of situation would give you a measure of comfort and protection as well as some idea of how to proceed.

[SassyRedhead]

Thanks Miranda. This gal is a frequent flyer here and we have done so much on so many occasions to attempt to accomodate, special dietary consults, talking to docs, etc. Every meal is at best unpleasant or at worst an all-out meltdown. I totally understand about her perceived lack of control and I really do empathize.

It's one of those situations however that as you attempt to accomodate you get hooked in for more and more "exceptions" to the rule. This time around she totally denied that she had diabetes, although she has been on meds for years. Doc d/c'd all meds, put her on a general diet and her BS skyrocketed, doc re-educated and restarted meds/special diet, nursing is supporting. Pt still angling for extras/special favors.

We are all just trying to do what is right. As I'm typing, I'm dusting off my nursing books to try to find some answers.

[rn/writer]

I can appreciate your dilemma. The sad truth is we can't save people from themselves.

I would encourage you to discuss this further with your manager and others. Even when a patient isn't so extreme, there can still be a clash between doc's orders and patient's rights. I'll be the first to admit that I don't know where that line is, and chances are, it's one of those that has a tendency to move.

As we all seem to agree, documentation is key. But beyond that, how do we, as nurses, navigate between the rocky shoals? Which principle takes precedence?

I don't envy you having to work with a patient who doesn't seem the least bit interested. Is the doc aware of her psych limitations?

I wish you the best.

[SCRN1]

I'd just try my best to educate them and then document very carefully everything I see and document with quotations everything they say. I'd also verbally tell the MD.

A different subject, but similar with trying to get a patient to comply with treatment...

I recently had a patient who was a hateful little thing who didn't want to do anything she was told. She refused being turned. Refused having a 3-day old INT d/c'd, refused dressing changes to her decub, etc. She was so exhausting to everyone who tried to work with her that no nurse had to be assigned to her two days in a row. When it was my time to take her, I went in with my supplies and just announced to her, "I'm here to do _____". (This was a different trip in after the initial assessment the beginning of the shift.) She looked and me and nastily said, "do you know about patient's rights? I have those rights!". In a calm, cool, collected & professional voice, I answered, "yes m'am, I do and you're right that you do. But did you know that if you don't allow the care that the doctor has ordered, he can release you from the hospital for noncompliance?" I might not should've said that, but it worked! She didn't argue with me about anything, allowed me to do everything I said I was there for and even became nicer and more agreeable with all the other nurses after that.

[Indy]

I'd have to agree with the poster who won't hand the lady her candy, if the patient can reach it herself. And if she's a fall risk then I would have to tell her not to get out of bed, please hit the call light if you need to get up. And document.

I have not had this exact scenario but I can understand where it would be like a catch 22. You're telling her to not get up, you won't hand her what she wants, and she's probably all sorts of ticked off. And to top that off you gotta document more than normal just to cover your butt.

I put her in the "broken hands" category of patient; it's my pet stereotype name for people who want things done for them that they can do for themselves. I do not now, nor have I ever, made it my personal practice to cater to that syndrome. And yes, it is tiring to write over and over again that things are within the patient's reach and that they do not voluntarily do range of motion for themselves, etc. But I believe I'm doing the patient harm if I allow them to get what they want, versus what they need. I'll explain to them what's going on, so they at least hear, if they don't believe, that I have their best interests in mind.

I usually get the opposite type of diabetic; the one who's deathly afraid of their bedtime snack and has to be educated on the value of a small snack in keeping the blood sugar decent at night. I do listen to my patients, and keep food available for the insulin-sensitive ones who say they bottom out; we all like to avoid brain damage. But I do not believe in handing people what's bad for them, if it's right there where they can get to it themselves.

Where I more often have this type of dilemma is the smoker who wants to avoid AMA discharge per the doc, so they'll try to stay in the room to sneak a smoke. As I remove the O2 adapter from the wall and stick it in my pocket, I say sweetly, "I sure hope you don't happen to need this oxygen, because if you're going to light fires in your room I can't have oxygen that close to it. In case you didn't know, that could start a real fire and I won't allow you to endanger the lives of my other patients." Usually that gets them to hand over the cigarette lighter, and the O2 goes back where it belongs. The policy is to call security and have them handle it. I haven't had to do that yet.

[Myxel67]

A diet order is a different animal from a chest xray, ultrasound, etc. It's not an all or nothing kind of thing.

If the doctor orders an 1800 calorie diet for pt & pt simply has no appetite and eats only 900 calories, are you going to try to carry out that order by going in and force feeding the pt. That amounts to about the same thing as refusing pt access to her belongings. There really isn't a legal issue here related to not enforcing the doctor's order. With diet, enforcing is a better term than carrying out. (Except for tube feedings and TPN, of course)

BTW, even though doctors continue to order it, the ADA diet no longer exists. In its place are recommendations to determine energy requirement of pt (based on height, weight, age, level of physical activity, and disease process). The energy requirement is expressed in calories. Dietitians in our diabetes care center recommend that the calorie count be split as follows: 50% carbohydrate, 20% protein, & 30%, but even that is not endorsed by the ADA.

Below is an excerpt from an article that appeared in 2002 in "Clinical Diabetes", the Journal of the American Diabetes Association.

To best understand the problem, it is important to look at the recently published ADA position statement titled "Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications."3 We are reprinting this position statement in this issue (p. 53).

There are several key points that require emphasis. First, the total amount of carbohydrate in meals and snacks is more important than the source or type of the carbohydrate consumed. Although different forms of carbohydrate do induce differing glycemic responses, the data reveal no clear trend in outcome benefit for any specific type of carbohydrate. The position statement notes that dietary sucrose does not increase glycemia more than isocaloric amounts of starch. Therefore, "intake of sucrose and sucrose-containing foods by people with diabetes does not need to be restricted because of concern about aggravating hyperglycemia. Sucrose should be substituted for other carbohydrate sources in the food/meal plan or, if added to the food/meal plan, adequately covered with insulin or other glucose-lowering medication."3

Because there is a great deal of individual variation in response to different sources of carbohydrate, it is difficult to make recommendations that apply to everyone with diabetes. By considering the total amount of carbohydrate in a meal and reviewing premeal and postmeal glucose measurements, it is possible to see how individuals respond to different types of food. Certainly, we see this on a daily basis in our clinic, particularly in those who frequently measure their blood glucose level.

Also relevant to my patient is the fact that he was acutely ill and had additional nutritional challenges other than his chronic illness. Why is it that everyone with diabetes seems to end up with the same dietary prescription when hospitalized? The ADA does not even endorse the "ADA diet"; it no longer recommends any single meal plan or any specified percentages of macronutrients for people with diabetes.4

Meal plans that specify "no concentrated sugars" or "no sweets" are no longer appropriate. These diets do not reflect current nutrition recommendations and unnecessarily restrict sucrose. Furthermore, they perpetuate the notion that restricting sucrose will result in improvement in diabetes control.

http://clinical.diabetesjournals.org...t/full/20/2/51

So you see, the physician has written a diet that can't be followed because that diet doesn't exist. By continuing to perpetuate outdated information, we do our pts a disservice. We should be crusading to get the hospitals to get rid of the insulin sliding scale and learn how to manage diabetes in hospitalized pts.

(You could count out 900 calories worth of the candy and tell her that's her carb allowance for the day. Remove carbs from tray. If she wants any of the carbs on the meal tray, she'll have to trade some candy for it.)

Sorry about the long post, but sometimes it's just got to be said.

[GingerSue]

[quote=ckben;2061074]

but by agreeing to be in the hospital, they agree to the care which nurses will give them, which includes giving them an appropriate diet.

[quote]


not sure about this agreement

eg. a diabetic lady was prescribed insulin and she refused the insulin, preferred to manage her diabetes other ways - according to her religion and alternative activities

I think that as nurses we have to respect the client's choice, try to inform and provide educational material, respectfully, and support their wishes

[cookie102]

all you can do is educate , educate, educate-----then document, document, document
people make all sorts of choices, unfortunately not all of them are good ones

[GardenDove]

Just because you're in the hospital doesn't require you to surrender your free will to everything ordered by the doctors and nurses. You are entitled to refuse things, even if your nurse disagrees with your choices.