concealed medicines?

Nurses General Nursing

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LPN1974, LPN

879 Posts

No, it's not like an emergency, and "implied consent" is when you hand someone the pill and say, "This is your blood pressure medicine" and the person then puts the pill into her/his mouth and swallows it ... The person didn't actually say, "Why, yes, I'm willing to take that medication," but the fact that s/he swallowed the pill indicates that s/he consents ...

I've worked for the last few years as a hospital surveyor/inspector for my state and the Feds. In my state, what many of y'all are talking about would be completely illegal, and it probably is in yours, too. Yes, if the state and/or Federal regulatory agencies found out, your facility would be in big trouble.

People do not automatically lose their legal right to refuse medications just because they are elderly or mentally retarded (or even because they are demented)! There's nothing wrong with crushing someone's medications into a spoonful of pudding or applesauce (assuming it's ok to crush the pills) because they don't like the taste or have trouble swallowing pills, but the person needs to be aware that the meds are in the pudding or applesauce and be willing to take them -- it's not ok to sneak meds into people (think about it -- would you think it was ok for people to medicate you without your knowledge and against your will?)

My state (and probably all states) has a legal mechanism for forcing medications on people against their will, and the state statute spells out the conditions that must be met. If those conditions have been met and the other requirements in the statute are followed, then it is legally permissible to medicate someone against her/his will. Otherwise you are breaking the law.

If someone has been adjudicated incompetent and has a court-appointed guardian, then it is the guardian who gives or withholds consent for medication (and everything else), and that is a different kettle of fish. But that means someone who has a legal guardian, not someone who is confused or difficult, and the family members are telling you they want you to do X, or its ok with them if you do X.

Well, as I said before, I guess this is something I need to bring up with my DON.

But this particular person I'm thinking of is NOT going to take her medication if I show it to her and ASK her if she wants it. It just won't happen. I've tried.

Then I started putting it in a spoonful of pudding, and just bringing it to her mouth from kind of behind before she has a chance to refuse, she opens her mouth and in it goes.

It's not like I held her down and forced her to open her mouth....I would never do that.

I didn't see what I was doing as "force". Just surprising her with it, is how I saw it, so I'll bring it up with the DON next time I'm at work.

elkpark

14,633 Posts

It's not force like wrestling her down and shoving it down her throat, but, unless she knows that the medication is in the pudding and is willing to take it voluntarily, you are medicating her against her will and that's illegal (unless she has a legal guardian who has given consent for the medication).

I've worked psych most of my career, and I've worked with the seriously mentally ill and the mentally retarded, and understand how frustrating and difficult it can be to get some people to take their meds. But they still have a legal right to refuse medication, just as we do, unless they have been adjudicated incompetent in a court of law and a guardian has been appointed (or it is truly an emergency situation).

However, as I mentioned, my state has a legal mechanism for medicating a person against her/his will if it is really necessary, and your state probably does, too. If you are in compliance with the state statute, then it's not illegal. I'm not trying to criticize any individual here; I know from my surveying experience that this is an area of healthcare that is often not well understood. I'm sure the legal counsel for your facility could clarify what the patient rights rules/regs are in your state that apply to medicating clients in your facility.

Gompers, BSN, RN

2,691 Posts

Specializes in NICU.

When I was a CNA in med-surg, I remember that nurses would tell me to let them feed certain patients because they wanted to slip their meds into the food. I don't know if it was to aid swallowing or to conceal the meds from the patient, but it happended on a daily basis. We had a lot of patients with dementia on the floors I worked on, and a lot of post CVAs. The way they'd usually say "slip" the meds in makes me wonder.

Off topic - but this reminds me of how we give meds to our cats. We gave up on trying to mix them in with food because the cats wouldn't go for it. Now we place pills in little balls of butter and the cats swallow that thinking they're getting a treat. If only it was this easy with humans!!!

CoffeeRTC, BSN, RN

3,734 Posts

Can anyone point me to the reg for this? This happens every day in LTC esp with the demtia res.

Lawnurse

129 Posts

elkpark, I agree with you.

The comment that "if these people were't MR they would know they needed their meds and take them" is inaccurate...does every non-MR person know they need their meds and take them? No - which is why we have the concept of informed consent.

Unless you honestly believe that the patient would say, if asked, "yes, I consent to take this pill" you don't have legal grounds to give it to them.

If you have to think about "sneaking" it into their food - chances are its because they DO NOT CONSENT, right? Otherwise you would just hand it to them?

The only reason (outside of a court finding of incompetence) it would be okay to sneak a pill into someone's food is if you had an EXPRESS (ie not just implied) agreement that the patient:

1) wants to take the medicine

2) wants to take it blended into food

3) understand and accepts the risks of not recieving 100% of the dose due to the administration through food.

LPN1974, LPN

879 Posts

Off topic - but this reminds me of how we give meds to our cats. We gave up on trying to mix them in with food because the cats wouldn't go for it. Now we place pills in little balls of butter and the cats swallow that thinking they're getting a treat. If only it was this easy with humans!!!

I do the same thing with my dog! He has seizures and is on Phenobarbital.

If I get the pill and approach him with it, and proceed to shove it down his throat like the vet showed me how to do, he is NOT going to take it.

It will come out the side of his mouth every time.

Soooooo....I started buying soft doggie snacks, and I hide the pill in a piece of doggie snack. Goes down 99.9% of the time. If it doesn't go down first time, we try again, until it does.

And the funny part is this.....He's become so accustomed to this by now, I have said this statement so many times to him...."Come on, we gotta go get your medicine!"......He WILLINGLY goes with me to the kitchen and waits for his medication in the snack.

Of course he's thinking "Oh boy, a snack!" and I'm thinking "Medicine!"

I can't afford for him to not have his medication...seizures will abound if he doesn't take it.

And I'm not comparing the MR people I take care of with animals, but it is the same with them also.... they MUST have their meds. They NEED their medication. Their health needs require it.

So just where is the happy medium in this?

As I said, I will bring up the situation with my DON when I go back to work tomorrow. I don't want to do anything that will get me or the facility in trouble, but as nurses who give the meds there, and my co-workers could tell you the same thing if they were on this board, that we have had it drilled into us, that it's just not accepatable for these people to not get their meds. I've heard the DON say several times, "It is your responsibility to make sure these people get every dose of medication they have coming to them."

There are very few who refuse, but there ARE those few.

I'll talk to her about it tomorrow and we'll see what her opinion is on this.

FROGGYLEGS, LPN

236 Posts

Thanks for sharing your experience, Elkpark.

I think I am pretty clear on this subject now with everyones help. I definitely won't be hiding any medication. I am going to pursue it through the MD and the DON and see if they can't come up with a legal alternative since this person isn't going to comply with the current plan.

LPN1974: I completely understand where you are coming from with the comment about the "happy medium". There really never does seem to be one. We are taught one thing and then expected to do something completely different in the end. I feel like the facilities I've worked for have had the mentality that we shouldn't "allow" them to refuse or that we are somehow lacking if we can't get the patients to take the pills. I can think of numerous patients in the past who would NOT take medicines for me on a regular basis; patients that you probably would have to force feed to get them to take it. I've been amazed sometimes looking at the MARs and seeing how that same person ALWAYS takes the same medicine from some other nurse. Sometimes it makes me wonder if they even took it at all or if the papers were just made to look nice. I've felt like volunteering to come in hours early just so I can see how they manage to get some of these people to take the pills- not to be a jerk but to just learn how they pull it off.

LPN1974, LPN

879 Posts

I've felt like volunteering to come in hours early just so I can see how they manage to get some of these people to take the pills- not to be a jerk but to just learn how they pull it off.

Yeah, it makes me wonder, too, just how the other nurses are getting them to take it.

I wrote in one of my posts about a person served, at my facility, who takes several meds, and if she refuses, then we have an order to give the Phenobarbital IM.

Well, guess what? I looked on the MAR for last month, and I am the ONLY nurse who has had to give it IM for the whole month, and I gave it several times.

This particular person....if she's in a good mood, she might take her meds, if she's not in a good mood, she's going to spit on you and slap you, and knock the medicine out of your hand. I don't know how it can be that I am the only one who is encountering her when she's in a bad mood.

So, yes, I would absolutely LOVE to see the other nurses give her medications to her.

Altra, BSN, RN

6,255 Posts

Specializes in Emergency & Trauma/Adult ICU.

In my state, I believe the only way meds can be given without pt. consent is

1) in an emergent situation - pt. is clearly an immediate danger to him/herself or others

2) if pt. is involuntarily committed to treatment by court order and 2 psychiatrists or other MDs certify that there is a need for pts. to get the meds whether they consent or not.

Still a student, so maybe it's naivete on my part ... but I'm a little shocked at the "slipping in a spoonful of pudding from behind" method. I'm not for a minute doubting that some pts. will refuse just because they can, but ... how can you submit someone to treatment without their consent (except as above)? Can there be a happy medium? People have free will, and can consent or not - it's a basic human right.

LPN1974, LPN

879 Posts

In my state, I believe the only way meds can be given without pt. consent is

1) in an emergent situation - pt. is clearly an immediate danger to him/herself or others

2) if pt. is involuntarily committed to treatment by court order and 2 psychiatrists or other MDs certify that there is a need for pts. to get the meds whether they consent or not.

Still a student, so maybe it's naivete on my part ... but I'm a little shocked at the "slipping in a spoonful of pudding from behind" method. I'm not for a minute doubting that some pts. will refuse just because they can, but ... how can you submit someone to treatment without their consent (except as above)? Can there be a happy medium? People have free will, and can consent or not - it's a basic human right.

I'm sorry that I have "shocked" you, but please try to understand where I'm coming from.

I give meds to aLOT of MR people, sometimes as many as 60-65 in one night.

Now I KNOW that patients have rights......and I know it isn't an excuse, but when you have worked on the same job for almost 25 years, under the SAME DON for MOST of those years, and you have been told, "It is your responsbility to make sure that every person gets every dose of medication they have ordered.", then it's just part of what you do.....do everything you can to get this medicine given.

Alot of these people take alot of behavior meds, seizure meds, and meds for an array of physical conditions, etc. and the directors and team leaders just don't want to see any refusals.

I honestly do not believe that I have INTENTIONALLY tried to violate anyone's rights by doing whatever I could to get them to take their meds.

I have worked on this job for a long time, and I genuinely care for the people I serve, wanting to do the best for them, not violating anyone's rights.

I think that my record of being on the same job for 25 years attests to that fact.

Froggylegs brought out some points that I agree with....you're taught one thing in school, then when you actually start working it's a different story.

I could just start letting this person refuse, and recording it on the MAR when she does, but how is that going to look on me....when I'm the only one she refuses it for and everyone else is getting her to take it?

Elkpark's posts are also very informative.

Sometimes things become so routine, that it pays to step back and rethink things, which is what I've been doing.

I can assure you, as I stated previously, that I will bring this up with my DON tomorrow, when I return to work.

We'll see what the outcome is of this.

Speculating

343 Posts

If the person is alert and orientated then you can absolutely NOT trick them into taking their meds. Not only is this morally wrong but you are committing an assault punishable by law no Dr.s order will save your rear or license.

leslie :-D

11,191 Posts

i was going to post exactly what elkpark stated.

it's clearly stated in the patient's bill of rights that they have the right to refuse treatment, even medicinal.

also, i too have felt the frustration of me being the only one to circle a med as being refused by the pt.

yet i also always felt deceitful if i tried to sneak it in otherwise.

even when i informed their doctors of the refusal and they would give an order to put it in pudding/ice cream, i still knew it was wrong and my conscience got the worst of me.

the only time i have ever given a med against a pt's will is if it was an emergency, i.e., haldol im.

yet ALL the other nurses had no problems mixing it w/a pt's food of choice....could never bring myself to do it....even if i do understand why they're doing so, i felt it was a betrayal of their wishes, and therefore, their trust.

what i would like to know, is if the person is severely demented and refuses meds, would their legal guardian be able to consent to us giving them meds in food? not the md, but the legal guardian who makes all the decisions on behalf of the patient? elkpark?????

leslie

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