Breech of ethics

icunurse1955 · Mar 15, 2006

You have a right to be concerned. Your classmate must have missed the class on patients rights. If the patient refused the medication even after the nurse has explained the importance of it, and that patient is in their right mind, then the nurse should have documented the refusal and not given the medication.

I hope that you will at least talk to her about this and express your concerns. If she was the patient and had good reason for not wanting to take medication, would she want someone to slip them to her anyway? I am sure that she wouldn't.

SharonH, RN · Mar 15, 2006

I'm an RN student one month away from graduation. Very recently a classmate of mine told me that while in clinical they have done the following:
They're in a patient's room with morning meds. The patient refuses a med, saying they just don't want to take it. The student replies, "Fine, but I have others here that you need to take..." such as their ABX etc... the patient indicates compliance and the student proceeds to open up all their meds (including the one(s) they have refused), place them in a cup, and then hand this cup to the patient. The patient takes all the meds not know that the one(s) they have refused are among them.
I was pretty appalled when I heard this. To me it seems like a violation of the patient's right to make their own health care decisions.
Your thoughts? Does it matter what the med is, what the reason is, or whether or not the person has dementia?

I agree with others who said that this is a definite breach of ethics, and no it doesn't matter what the med is. HOWEVER, whether or not the patient has dementia IS a factor. The patient may or not be able to make an informed decision about their care and someone else who has healthcare power of attorney might be the one who is making the decisions about such things. Patients with dementia refuse food all the time and what do we do? We stick a feeding tube in them. They remove IVs and Foleys because they don't want them and we reinsert them and tie their hands down (at least we used to before everyone started moving to restraint-free facilities).

Bottom line, there needs to be some clarification and perhaps a patient care conference to discuss whether or not this patient is able to refuse certain meds.

bonjovigirl · Mar 15, 2006

When I first read the post I thought the same as the rest of you, that said student was wrong. HOWEVER, if the pt has dementia and isn't all there, is it the same breach of ethics? If I failed to admin meds to every dementia pt that originally says no, nobody would ever get meds. Not saying that I shove meds into a pts mouth, but if for fourty five minutes they were talking to their great aunt faye that died 20 years ago, I may not take their objection as seriously. Most of our pts that aren't completley with it refuse EVERYTHING. How many times have you all cleaned up a person covered in bm that was telling you to leave her alone?

Now, if the person was "halfway" with it, I would have tried to find out her objections. She may just not understand why shes getting her med. I would not sneak a med to a person who was coherant. EVER. Not only do they have the right o say no, but I DO NOT HAVE the right to force them to do anything.

In other words, I agree with sharon.

Marie_LPN, RN, LPN, RN · Mar 15, 2006

Kinda make me wonder what else goes on.

Horrible.

olichi · Mar 16, 2006

Do anyone know what the ethics of nursing shortage are.How do the current nurses feel about the nursing shortage.

luvmy2angels · Mar 16, 2006

This happened to me during clinical as well. I had been having the same pts for about 2 weeks and my one resident refused one of his pills, I asked him why and he stated that it gave him diarrhea. He took all the others though and I made sure to chart that he refused the one med and why. When we switched pts I explained to the student taking over my assignment to ASK Mr so and so if he wanted all of his meds. I have a habit of telling my pts what meds they are taking before I give them. She said okay but I later found that she put the med in with all the others too after he said he didn't want it, I asked her why she would do that and she said, Well the Dr prescribed it so he better be taking it, he doesn't need to know that I mixed it in with all the others!" I told my instructor because I just couldn't believe she would do that. She ended up having a med error on her record. And NO I don't feel bad for telling the instructor what she did. WE are supposed to be advocates for our patients and I feel that is what I did.

zacarias, ASN, RN · Mar 16, 2006

It sounds as though this person was A&Ox3. But seriously, if this person was demented and takes Coumadin every day for afib, what do we do? If the patient says "no" and I don't give it, I'm not gonna go home and think "wow i did good work today, I was a pt advocate and didn't force a med that is saving this person's life even though he has no clue that it is."

Generally, giving a med that a pt refuses is unethical but sometimes there are situations like the above.

clee1 · Mar 16, 2006

And NO I don't feel bad for telling the instructor what she did. WE are supposed to be advocates for our patients and I feel that is what I did.

:yeahthat:

I am no tattletale, and I dislike those that are, but we are here for our patient's benefit; not that of our classmates.

Cut class, tell an off-color joke, be tardy, skip out early.... no problem to me - I won't snitch you out. However, make a med error or violate ethical standards and I know about it.... consider yourself busted! :nono:

Nursing school is a place to learn the practice of nursing: it is NOT a place to cover for your sorority/frat buddies. The stakes are just too durn high!

rn/writer, RN · Mar 16, 2006

It sounds as though this person was A&Ox3. But seriously, if this person was demented and takes Coumadin every day for afib, what do we do? If the patient says "no" and I don't give it, I'm not gonna go home and think "wow i did good work today, I was a pt advocate and didn't force a med that is saving this person's life even though he has no clue that it is."
Generally, giving a med that a pt refuses is unethical but sometimes there are situations like the above.

Several people have raised this very important question. If, indeed, a patient has dementia serious enough to warrant overriding their choices about which meds they will and will not take, then there should be someone appointed as their healthcare power of attorney to make that decision on their behalf. And the student should have discovered this in her prep time and been able to cite the particulars to anyone who challenged her.

The danger with such a situation is that it is far too easy to dismiss the objections of a dementia patient as part of their delusional thinking. Time pressure aside, it is important to listen to what the patient is saying, especially when introducing a new med or making some other change. Evaluate the characteristics of the refusal. Is it a random resistance--some days she'll take the meds, other days she won't--or is there a consistent objection? Does she fight the morning meds, but charting indicates the HS meds go down without a problem?

Dementia patients can have the same side effects, adverse effects and bad reactions to meds that the rest of us have, and some of them have enough of their wits left about them to make the association with the med causing the problem. The difficulty is that they may not be able to communicate their distress in any meaningful way except to balk at taking the offending med or all their meds in general.

It becomes our responsibility to observe and listen, even if only for a few seconds, and consider that input with the patient's well-being in mind. It's too easy with patients who have communication impairments--whether through dementia, stroke, psych issues, or other problems, to disregard what they are saying because we assume it has no meaning.

Back to the OP--it didn't sound like the patient in question had any cognitive issues, in which case, the other student crossed the line.

CoffeeRTC, BSN, RN · Mar 16, 2006

Lots of good posts.

Just remeber that if a person is refusing the meds, the doc needs to know about it.

mystcnurse, MSN, APRN, NP · Jun 27, 2006

With that said, I wonder why it is that most times on this board when someone does something questionable, their morals and character immediately come under attack. Is it not within the realm of possibility that this student has a great character and good morals, but is misunderstanding the reasons why it's ok for a patient to refuse a med? If I may play devils advocate for a moment, isn't it plausible that the student nurse understood the importance of the patient receiving the medication and felt that by tricking the patient into taking it, it was serving a greater good?

This is one of the most helpful comments I have ever heard from a nurse, in my life!!! You are right. I think also, it may be slightly confusing to students, at times, ESPECIALLY when dealing with patients with dementia. I mean, what if your demented patient who just pulled her foley out and her IV while trying to get her osteoporosis laden body out of her bed, refused her restraints????? Wouldn't you say something like, "I'm just going to put this little belt on you"??? Does that make you a liar and a patient hater? Food for thought....

I just hope that the nursing instructor would take an opportunity to use such an indescretion as a teaching moment, and not a reaming moment.