Alert,oriented LTC patients who refuse routine nightly insulin?

[Blackcat99]

What is your LTC policy for alert oriented patients who refuse to take their routine ordered nightly insulin? She just says she doesn't want it and doesn't need it. What would you do?

[Blackcat99]

What kind of insulin would she be on that testing her sugar twice per week is sufficient?

She gets lantus insulin every night. She took it tonight after I told her that I would have to call the doctor each time she refused. She said that she felt she was getting too much and I encouraged her to talk it over with her doctor.

[joanna73, BSN, RN]

Depends on the medication. Patients have the right to refuse, but if they are refusing insulin, I would be concerned. One night probably won't harm them, but over a period of time insulin deficiency is a problem, as we well know. I would document, provide health teaching on the subject and inform the physician, the family, and the dietician. Together with the patient, we could revise her care plan. Ultimately, she can refuse, but I'm not willing to deal with an emergency simply because someone doesn't feel they need their insulin.

[SHGR, MSN, RN, CNS]

She gets lantus insulin every night. She took it tonight after I told her that I would have to call the doctor each time she refused. She said that she felt she was getting too much and I encouraged her to talk it over with her doctor.

Her concerns are legitimate. In "people with limited life expectancy" an a1c goal of 8, rather than 6.5 or 7, is recommended in the literature due to increased risk of complications from hypoglycemia and less need to worry about long-term risks of hyperglycemia. However remember too that with insulin your choices are not just "give this full dose or don't give any." She may need a smaller dose indeed and a couple of fasting BG's would tell you that.

Also if you are the nurse in the facility, it is your responsibility to talk to the doc about this, no?

[Blackcat99]

The doctor at this LTC is super good. He is here 4 days a week and visits his patients frequently. I talked to the Doctor yesterday about her refusing insulin sometimes and he asked me "Did she say why she refused? and I said she said she doesn't need it. He has not written any new orders yet in regards to her insulin.

[KbmRN, ADN]

What are her sugars HS? Of course document, notify DON/MD. Teaching for pt is crucial.

[Blackcat99]

She only has accuchecks twice a week as per MD's orders.

[NutmeggeRN, BSN]

I agree with the documentation and notifications listed above and would also add the DMPOA if that is activated.

[tamadrummer]

Shoot let them end up in DKA and on endotool or some other algorhythm And the amount of sticks for blood sugar and the pain in the butt it becomes for them will teach them. Blindness and losing appendeges is way further than a good stent of DKA.

Sent from my iPhone using allnurses.com

[BrandonLPN, LPN]

I know I'm going to get blasted for this, but I have a similar pt who has an order for 15 units of novolog with meals. He is alert and oriented, too. Every night he tells me to give him less than the 15. He always says "give me 7 units tonight" or something like that. I say "okay" and give him the 15 units anyway. What he doesn't know won't hurt him. And the doctor knows I do this and finds it amusing.

[CrunchRN, ADN, RN]

I think an alert and oriented person who is trapped in a freaking nursing home should be allowed to make their own choices as long as they understand the implications.

God save me from well intended people making those decisions for me. I would rather be dead any day.

[BrandonLPN, LPN]

I think an alert and oriented person who is trapped in a freaking nursing home should be allowed to make their own choices as long as they understand the implications. God save me from well intended people making those decisions forme. I would rather be dead any day.

If you won't follow the doctors treatments, what's the point of even being IN a nursing home. If these people were capable of making these kind of decisions they wouldn't be here in the first place. By definition of their being here they can't take care of themselves....

[CrunchRN, ADN, RN]

Well. I wouldn't be there by my own choice, but we all know that many people become disabled eventually due to age and infirmities and you will be "put" in a nursing home whether you want to or not if unable to care for your self and no family available.