Moral Dilemmas: Two Scenarios - What would you do?

[MichelleDawnLPN]

[color=#808080]hi, i'm new here (first post) so i hope i'm posting this in the right forum!

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[color=#808080]i realize that in nursing we will encounter a lot of grey areas when it comes to ethical/moral issues but i'm hoping y'all can help me with two scenarios in particular.

[color=#808080]1) we have a resident "paula" in our ltc facility who is orientated x3 but has what a psychiatrist has termed a drug-induced paranoia that has been going on for over a month. the doctor tells us to be patient and it will wear off therefore he chose not to send her to a psychiatric facility. she will often refuse to eat saying we are trying to poison her and is refusing peri-care and won't wear an incontinent system although she is frequently incontinent. she wants to smell everything (blankets/clothes/towels, etc.) before they come in contact with her and will often refuse to use them or make us get another clean one. she will no longer sit in a lounge/recliner chair and is refusing to get into bed at night (saying it burns her) so she sometimes sits all day and sleeps through the night in her wheelchair. she has parkinson's so her mobility is impaired. when we try to gently coax/reason/plead/be firm with her she says she pays to live in this home and she knows her rights and we can't force her to do anything. i understand that she has the right to refuse but we have a responsibility to care and this whole situation leaves me feeling very inadequate as a nurse. we, lpns and rcws on the floor have addressed our concerns to our supervisors many times but there has been no real response other than to "be patient with her." that would be understandable for a few days but this seems to be an ongoing issue and it's very unhealthy. either we neglect to provide the care necessary or we do cares against her wishes while she pushes us away -this does nothing to improve her paranoia that we are trying to kill her. honestly, i feel she should be in a psychiatric facility where they are better able to monitor, assess, address these issues with a comprehensive care plan, but that's not my decision to make. depending on the rn in charge we will either be told to let her refuse or to force her to comply. our interventions are very inconsistent and that only makes the situation worse.

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[color=#808080]2) another resident, "mary" is unable to ambulate herself and depends on staff for total care. she is orientated x3 but her judgment is impaired. she frequently asks for the cordless telephone to call her daughter, but her daughter has indicated that her mother was abusive and she doesn't want her mother calling her. she visits occasionally on her own terms. mary knows her daughter's phone number and where she works. when she asks for the phone we (staff on the floor) are told to tell her that the phone isn't working/can't be found/is charging, etc. this could go on for the better part of a shift and mary knows she's being lied to... she'll say, "why are you doing this to me? why won't you let me use the phone?" mary suffers with depression and i realize it would be hurtful to tell her that her daughter doesn't want to be contacted. (in fact, i'm guessing her daughter doesn't want us to say that to her and would rather we distract/lie to her.) but that leaves us in a very uncomfortable position: lying/denying the phone to someone who knows very well what is going on.

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[color=#808080]can you offer any insights here? what would you do?

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[color=#808080]i realize these aren't black-or-white issues but feel very uncomfortable with the care plans (or lack thereof) for these individuals.

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[color=#808080]thanks, michelle

[gentlegiver, ASN, LPN, RN]

Sometimes it's the Per-Diem Nurse who see's things that the full-time people miss. It's not because they are uncaring, it's because sometimes things happen in slow stages. Example: I worked with a pleasant LOL, co-operative, no problems. A week later I came in and she was starting to refuse meds and care. A week after that she was yelling at staff. The staff didn't really notice the changes because she didn't just wake up changed. It occured over a 3 week period. I noticed it because I was not there everyday, I called the Dr and requested a U/A, sure enough she had a UTI, once treated she returned to her sweet self. Even if your new, or don't work 5 days a week, don't be afraid to speak out if you see changes in a patient.

[leslie :-D]

for #1, if it has been over a month, yes- get a re-eval from psych.

and meticulous documentation.

#2, it'd be a cold day in hell before i ever lied to a pt.

if distraction doesn't work, and you cannot call physician, then defer to the rn.

but keep in mind, working 3 shifts/wk, you may not be seeing the big picture.

do you know what's been discussed in meetings?

do you know if the licsw has been involved?

as to the pt, apologetically tell her that "i'm sorry, but i just cannot allow you to do this...you need to talk to x, y, or z for a more specific explanation.

be sympathetic and sincere, of course.

the bottom line is, do not lie...ever.

we nurses are supposed to be the ones that pts trust.

don't ever do anything to destroy that 'therapeutic' relationship...

esp in long term care, where relationships do happen.

best of everything.

leslie

[mazy]

Scenario #1 I've seen. It happens when the dr. does give those orders to be patient and so it becomes incorporated into every dialogue about the patient, "well, the pt is doing this that or the other what do we do?" And then the response is to be patient and then weeks go by and sometimes month and then someone (maybe someone like yourself with fresh eyeballs) comes along and says "this has been going on a long time, has the dr. been notified?" Oooops. Well, no, everyone was just being patient. So yeah, looks like an eval needed.

Scenarion #2 -- get social services involved. Family dynamics and psych/soc issues are what they are there to deal with. That is not your job.

It is weird though that the direct care nursing staff isn't allowed to contact the dr. Not a very efficient system.

[rngolfer53]

Patient #1 - needs to be further evaluated. They can't just let her sit there, change the meds, give you PRNs, etc... how awful is it for her to be paranoid, upset, anxious, etc... and just be told to "wait it out" - not fair to you or her!

Patient #2 - It isn't my job to spare a patient from family drama and I am not going to lie to them. Our lying to patients does nothing but allow their family to skip out on the responsibility. "I'm sorry, but your daughter has requested not to speak with you. I cannot bar you from using a telephone (this isn't a prison, after all), but your daughter does not want contact with you at this time and you can do with it as you please."

Agree. The daughter, if she finds the calls from the mother intolerable, can always block calls from that number, or screen with caller ID, etc. It's her call, so to speak.