Alert,oriented LTC patients who refuse routine nightly insulin? - Page 4

What if he doesn't eat his meal? Do you still give the 15 units? Does he count CHOs or have SSI? Have you done any education on your A&O patient about what is ordered? Can you say "what he doesn't know won't hurt him" if you're not educating him about the order? What you're saying here is that you're lying to your patient/going against his verbal preference (with an amused doc's knowledge... don't get me started there because you're the one posting, not the doc) and that's ok with you?

That's not ok with me. I'd educate, give what the patient requested (7 units is better than 0), document, and communicate again with the doctor. I truly believe what you're doing just isn't right.

It wouldn't matter to me one way or another whether the resident takes the insulin. Give education etc., but the problem with LTC regulations is that it's really not feasible to notify the MD at night every time this person refuses the insulin. The nurses don't have time to fool with that *every* night, and I'm certain the MD will NOT appreciate those calls. After a week or two of circled initials (or whatever) it should have been discontinued.

Then get the order DCed or modified during day shift when the PCP is available. I'm not advocating calling the PCP/ER at night. If it's documented that the patient refused and it got passed along to day shift to notify the PCP to modify/DC the order, then you're covered.

And it should matter to you if they got their insulin or not. Not only is it a prescribed med, it's insulin.

It doesn't matter -- if they're not going to take it anyway! The bi-weekly accuchecks are more of a red flag to me than the daily refusals. Thankfully I work in acute care now and don't have to go through all the baloney when someone refuses a med, but I believe it depends on facility policy and specific state as far as MD notification. Every facility I've worked at required a notification right there if a "high alert" med was refused or held - not that it was always abided by - my point being that passing it on to day shift to notify isn't always acceptable in all circumstances.

Of course I make sure he eats his meal. And most LTC residents are not on SSI or carb counting. They just get a set dose with meals, the nurse obviously having the privilege to withold if he's not eating, vomiting, etc.

I think people are either misunderstanding the situation or they just aren't familiar with LTC. The kind of resident I'm referring to is technically A+O x3. But he is far from competent. He is delusional about his disease and says things like "I only need 2 units for my BS
of 390 because I'm going to go for a walk around my room tonight." pt teaching is not an issue here. Believe me, *everyone* is aware of the situation. It's part of his personality disorder. No amount of
teaching in the world will change that. Manipulative noncompliant diabetics end up in LTC all the time precisely because they can't be trusted to manage their medication. This is his home. End of the line. Not rehab. No one gets out alive. Were not trying to teach him how to manage his own insulin regimen.

And in LTC I *can't* just give the 7 units he requested, even if I wanted to. Not without a doctors order.

If we stopped everything every
night and did "education" and put it on sick call and held his insulin and tried to tinker with the dose every day I would never get my job done. I have 49 pts to tend to. Not 6 or 7 like in med surg. The process has to be streamlined. And the doctor would have a meltdown. And rightfully so. I don't think some people understand what LTC is all about.....

To put it even more simply anyone who has ever worked in LTC knows there are residents who will *never* be satisfied with their insulin dosing and will argue with the nurse every darned time. If the doc changes the dose to 7 units, tomorrow he'll want 10 units. If he says he needs a sliding scale today, tomorrow he'll just complain about each separate possible dosing. There comes a point when teaching ceases to be a central part of a pt's nursing process. These people *aren't* going home. He is *never* going to administer his own insulin. A licensed nurse will be giving him his medications until the day he dies. So do you *really* think he needs education and physician involvement every day when he contests his insulin dosing? Really?

I agree with what you are saying to a point with regard to not having the time to debate/educate/call MD every night.

However, if a person is in LTC because they are physically unable to care for themselves, but are mentally competent (even if somewhat loopy to your thinking) then it is their choice.

At that point the doc should be discussing it with them and then if they don't want it or want less and are mentally competent then the order should be changed.

Maybe they are ok with dying at some point from high BS. Shouldn't that be their choice? Why should they be forced to maintain a healthy BS and thereby live much longer when they are already at a nursing home.

Look, I know you all work so hard to take great care of the residents under really impossible circumstances. However, for me, this lack of regard for my own ability and right to make my own choices and deal with the result is just horrifying. Horrifying.

Well, I don't think we're talking about the same kind of resident here. If someone *really* understands the consequences of refusing treatment and they are willing to face the consequences (ie death) then I agree with you. The kind of residents I'm talking about simply have deep emotional/personality/whatever problems that skew any sort of judgement. Their behavior is linked more to delusion and a desire to cause conflict than anything else. Totally different from the pt you describe who is institutionalized strictly due to physical handicaps but can still make rational decisions re: his medications.

I am glad you can tell the difference.

Interesting interesting interesting convo. As with many decisions it boils down to "protect the patient or protect your license?"

On one paw I say follow facility policy and doctor's orders no matter what. Make sure to get crystal clear orders from MD & discuss plan with DON, and stick to that.

On the other paw, I wouldn't want to deal with a DM patient on my panel going into shock, the ED or dying on my shift and having MY name on the dotted line that I didn't admin insulin as the cause.

Wonder what a medical ethicist would say. Or a geriatric specialist MD.