Depressed patient refuses positioning even though she is lying on her own bowel movement

  1. Hi everybody, I am still a nursing student and have encountered a big ethical issue in placement. The ward got an elderly lady about 80 who just went for hip replacement, she was also depressed and bereaved due to her daughter dying last week due to cancer. I tried my best to make her smile because she cried a lot. It was all okay until we spotted that she had moved her bowels and I could smell urine. When we tried to re position her to clean her, she kept shouting at us and said she didn't want to and that we were abusing her by forcing her to. I am aware it is our nursing duty to act beneficently and "do no harm" however I felt like we were disrespecting this lady's autonomy. I am confused what would be done in this situation because she technically lacks mental capacity, my shift finished and never got to find out what happened. I would like to know what everybody here thinks would be the ethical thing to do for this lady.
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  2. 27 Comments

  3. by   LovingLife123
    The ethical thing is to clean her up and not allow her to lay in feces and urine. She is obviously not in the right state of mind right now.

    Laying in feces and urine will cause skin breakdown and infection that could be deadly. It's a huge ethical issue to not clean her up.
  4. by   MissHannaway
    So is it ethically right to restraint a patient and perform care against her will in these cases, do we not need to perform any assessments to see if she has capacity and involve family and power of attorneys?
  5. by   Sour Lemon
    I feel like I don't have enough information to give a definitive answer, but my first thought is that she's probably in a lot of physical pain. I'd work on getting that under control and then worry about getting her clean.
  6. by   NurseSpeedy
    If she's truely mentally incapacitated (and documentation of some kind would seriously help here) then she definitely needs to get cleaned up or she is going to have breakdown /infection/a whole new list of issues.

    First off, address pain. Any bone surgery hurts like a (fill in the blank). Make sure her pain is controlled and try to do cleaning/repositioning when meds would be most effective in relieving pain.

    TALK to this patient about what can happen if she doesn't turn. Then, as a student you have plenty of time to do even more if this than we do, sit with the patient and LISTEN to what she has to say. Let her express what she feels she needs to express-pain, anger, grief. Consider involving a grief counselor or religious visitor if the patient is willing to accept these services. A psych consult may be beneficial for possible short term medication to help her deal with her grief. I know that you want to help her by trying to make her smile, but she may need more listening than someone trying to make her smile at this point in the process. Hopefully, knowing that you are there for her and trying to help will get her to go along with the clean up.
  7. by   LovingLife123
    Quote from MissHannaway
    So is it ethically right to restraint a patient and perform care against her will in these cases, do we not need to perform any assessments to see if she has capacity and involve family and power of attorneys?
    Why would you need to get attorneys involved? This involves cleaning a patient who is laying in feces and urine. Attorneys will most certainly become involved when skin breakdown and infection occur.

    To let somebody lay there in feces and urine who is depressed to begin with and says they don't want care which is probably due to the severe depression they are experiencing is inhumane if you ask me.
  8. by   LovingLife123
    Quote from NurseSpeedy
    If she's truely mentally incapacitated (and documentation of some kind would seriously help here) then she definitely needs to get cleaned up or she is going to have breakdown /infection/a whole new list of issues.

    First off, address pain. Any bone surgery hurts like a (fill in the blank). Make sure her pain is controlled and try to do cleaning/repositioning when meds would be most effective in relieving pain.

    TALK to this patient about what can happen if she doesn't turn. Then, as a student you have plenty of time to do even more if this than we do, sit with the patient and LISTEN to what she has to say. Let her express what she feels she needs to express-pain, anger, grief. Consider involving a grief counselor or religious visitor if the patient is willing to accept these services. A psych consult may be beneficial for possible short term medication to help her deal with her grief. I know that you want to help her by trying to make her smile, but she may need more listening than someone trying to make her smile at this point in the process. Hopefully, knowing that you are there for her and trying to help will get her to go along with the clean up.
    This. 100%
  9. by   MissHannaway
    Thank You so much, I am only a first year nursing student and already spotting so many ethical dilemmas coming into play in nursing. We had just learned about the ethical principles and i was just trying to weigh them together for what is in the patients best interests. I will definitely reflect on this and take it on to the future.
  10. by   Wuzzie
    Quote from LovingLife123
    Why would you need to get attorneys involved? This involves cleaning a patient who is laying in feces and urine. Attorneys will most certainly become involved when skin breakdown and infection occur.
    Not attorneys..."power of attorneys" as in someone who can make decisions for the patient when the patient cannot act in her own best interest.
  11. by   hppygr8ful
    Quote from MissHannaway
    Hi everybody, I am still a nursing student and have encountered a big ethical issue in placement. The ward got an elderly lady about 80 who just went for hip replacement, she was also depressed and bereaved due to her daughter dying last week due to cancer. I tried my best to make her smile because she cried a lot. It was all okay until we spotted that she had moved her bowels and I could smell urine. When we tried to re position her to clean her, she kept shouting at us and said she didn't want to and that we were abusing her by forcing her to. I am aware it is our nursing duty to act beneficently and "do no harm" however I felt like we were disrespecting this lady's autonomy. I am confused what would be done in this situation because she technically lacks mental capacity, my shift finished and never got to find out what happened. I would like to know what everybody here thinks would be the ethical thing to do for this lady.
    By what criteria are you basing a lack of capacity? Simply being elderly and depressed does not imply a lack of capacity. Is she suffering from dementia or other cognitive decline. Capacity is a legal definition. Is she otherwise alert and oriented. Can she state that she understands the consequences and health risks of not being cleaned up. Was she adequately medicated for pain prior to the activity in question. A psych consult is probably in order.

    Hppy
  12. by   Davey Do
    Under such conditions on the Geriatric Psych unit we typically put the Patients in a "Therapeutic Hold".

    Now, that doesn't mean that we always do the paperwork and get a Physician's order. I will sometimes chart "Patient therapeutically held while providing hygienic measures for bowel and bladder incontinence".

    If we allowed every Patient who refused direct care to have their way, we'd be knee deep in... you know.
  13. by   MunoRN
    There are very clear requirements for ignoring a patient's right to refuse, failing to abide by those requirements is a crime, sometimes even a felony so it should be taken seriously. If the patient is truly incompetent, which is a fairly high legal standard, permission to provide interventions against the patients refusals must be obtained from the POA or court appointed surrogate.

    The first step would be to address why she is not wanting to be turned for a clean up, and in the case of a hip replacement this is likely due to acute pain with turning the hips, proper treatment of this pain prior to turning is expected whether or not the patient is hesitant to be turned.
  14. by   hppygr8ful
    Quote from hppygr8ful
    By what criteria are you basing a lack of capacity? Simply being elderly and depressed does not imply a lack of capacity. Is she suffering from dementia or other cognitive decline. Capacity is a legal definition. Is she otherwise alert and oriented. Can she state that she understands the consequences and health risks of not being cleaned up. Was she adequately medicated for pain prior to the activity in question. A psych consult is probably in order.

    Hppy
    I am in no way saying that the patient in question should not be cleaned up and gentle force as in Therapeutic holds may be warranted - But I have found on more than one occasion when a patient like this refuses care there's more too it. Is the staff in question in a hurry and not paying attention to the patients facial and body language. Pain is usually a big issue with hip fracture patients and a lot of reassurance and a touch or pain medicine often gets the job done. When I worked with the elderly population I found several factors were involved. Patients feel infantilized, embarrassed, in pain etc.... A few gentle questions to figure out what the problem is can really make a difference.

    Hppy

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