can confused pts refuse meds?

MunoRN, RN · Mar 20, 2018

Right, I understand your point Chare. Like many aspects of medicine, I suspect this issue is different from state to state. In the state within which I reside (Ohio), legal next of kin can and do consent for a wide variety of things for confused patients who have not been deemed incompetent. They consent for blood products, colonoscopies, surgeries, admission to skilled nursing facilites upon discharge, and code status. If a confused patient will willingly take a b/p med crushed in pudding, her b/p is 185/90, and the family member wants her to take it....that feels like a win win. That doesn't mean I'm going to hold her down and force the spoon in her mouth.
Injections are more of a grey area because they cause pain. That's why I don't feel comfortable giving advice for administering injections to unwilling, confused patients on a public forum where nurses practice in many different states and countries. At my hospital, in these types of situations, ethics and legal is generally involved.
One caveat. In my state, a living will/advanced directive trumps a legal next of kin for code status.

The basic legal principle of consent and right to refuse treatment don't vary from state to state. Being confused is not in itself a legal justification for denying a patient the right to refuse. In order to be considered competent and able to refuse any treatments including medications, the patient only needs to be able to convey understanding of what we think is wrong with them, the treatment we are proposing, and what the risks are of declining the treatment, it doesn't matter if the patient thinks it's 1998 in regards to their right to refuse.

kbrn2002, ADN, RN · Mar 23, 2018

I see this at work pretty regularly. I work with an elderly population, many of them have dementia to varying degrees. All of the residents that have dementia also have a medical power of attorney giving somebody else the right as well as the obligation to make health care decisions for them. The right to make those health care decisions does not include the right to force the resident to comply. If the resident chooses to refuse a med, treatment or even basic cares it is still their right to do so.

Buckeye.nurse · Mar 23, 2018

The basic legal principle of consent and right to refuse treatment don't vary from state to state. Being confused is not in itself a legal justification for denying a patient the right to refuse. In order to be considered competent and able to refuse any treatments including medications, the patient only needs to be able to convey understanding of what we think is wrong with them, the treatment we are proposing, and what the risks are of declining the treatment, it doesn't matter if the patient thinks it's 1998 in regards to their right to refuse.

I think we approached the question from two different angles Muno. I wanted to clarify what I said to see if it makes sense to you, because I agree with pretty much everything you post, and value your opinion. I 100% agree that confused patients retain the right to refuse. Almost every confused patient I've cared for was pleasantly confused. They would agreeably take anything I offered them. They didn't *understand* why I was giving the med to them though, so I educated the next of kin, and answered any questions or concerns they might have. That, in my mind, is consent (the educated agreement to accept a treatment). I educated the confused/delirious patient to the best of my ability, and they assented by willingly taking the medication. On the occasion they refused, I documented that, and notified the MD.

If a delirious patient requires surgery, and it isn't urgent (a patient sent from a SNF with a femur fracture for example), surgeons wait a few days to see if a patient's mental status improves, and they have the capacity to consent. If it is urgent, or they remain delirious (and are determined by the physician to lack capacity), assent is obtained from the patient, and informed consent is obtained from the next of kin.

I hope that cleared up what I was trying to say. I understand the confusion because the thread is asking if patients have the right to refuse, and I went on a tangent. I was just trying to say that we as nurses, also have the obligation to advocate for our patients if we doubt whether they understand what they consented for...and I don't think that's how my previous posts came across.

Meriwhen, ASN, BSN, MSN, RN · Mar 23, 2018

If a patient is legally competent, they can refuse medication even if the refusal will be detrimental to them. The fact that the patient is confused doesn't suddenly make them incompetent, nor does it justify you forcing medication on them. And if you lay hands on the patient against their consent in an attempt to force those meds, you've just committed an act of battery.

However, you can certainly engage whatever mental and verbal tactics you know in order to try to get them to take it. And though I do not agree with outright lying to patients, even those who are psychotic...I also think that there's times when being a little vague and sneaky can be helpful.

I'm also not opposed to bribery (within reason): a snack, coffee, watching some television, whatever the carrot might be for that particular patient.

KelRN215, BSN, RN · Mar 24, 2018

I'm a pediatric nurse and most of our patients are unwilling recipients of their medications. But children, in general, don't get a say so it falls to the parent. And yes, there are times when an army full of nurses has to hold down a flailing 5 year old to get medications into him. If it's something like colace or senna that the surgeon just ordered because everyone gets colace or senna after surgery and either the kid is pooping fine or hasn't even started eating yet post-op, who cares if they refuse. If it's something critically important- like parents who won't agree to give their diabetic kid insulin or something like that, it's time for the state to step in. I have a patient right now who's in state custody because his parents wouldn't give him the prescribed medications for his aplastic anemia or return the MD's phone calls when he had critical lab values.

It's a completely different story with a competent adult and, as others have said, confused does not equal incompetent. When my patients turn 18, if they all of a sudden want to stop taking the meds they've been taking since childhood for whatever reason, all gloves are off. At my last job this is something I saw occasionally with my college aged CF patients. But, unless deemed incompetent, adults are free to make bad decisions.

HiddenAngels · Mar 25, 2018

I'm not sure YOU can force anything on a patient once they refused. Maybe a psych patient idk, not my specialty but no means no. Call the doctor or shift supv asap..