Patient with Dementia's Right to Refusal - page 2

by oblivionenigma

12,352 Views | 21 Comments

Hello! I have a bit of an issue. There are certain patients I often take care of who have profound dementia--to the point of requiring hand-over-hand assistance for eating, unable to consistently reposition self in bed, etc--in a... Read More


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    Is this a SNF-specific thing, like the "no restraints" rule? I work in acute care, on the psych C&L service at a large academic medical center, and a pretty good chunk of what we do all day is evals on individuals to determine whether or not they have capacity to refuse tx. I've never heard anyone suggest that there could be such a thing as a person having the legal right to consent or withhold consent for treatment, or anything else, despite being, let's say, for the sake of discussion, profoundly demented.

    I would be v. surprised if this is, in fact, "the law" in whatever state the OP is in. And if it simply company policy, I also would question whether the legal counsel has been sufficiently involved. This is going to come back to bite the facility at some point ...
    Sadala and oblivionenigma like this.
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    I think the OP gets the point that an advanced dementia patient can no more refuse their care than can a 5 year old.

    What they often can do, however, is to demonstrate to us those things in our POC which are frightening, unpleasant, or uncomfortable for them as that is often when they act out. The patient may not be able to refuse an intervention but we as professionals can certainly determine when an intervention is more problematic than effective. When we discover those things we can discuss them with the care team and family to devise a new and improved plan for the patients care and comfort.

    Good luck.
    dudette10, GrnTea, ktwlpn, and 1 other like this.
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    Quote from jadelpn
    Then the company policy needs to have more than "a patient can't refuse". Because then you could be brought up on neglect charges. Can this be brought to administration with a suggestion that their (or parent company's) legal team give direction, and if it is found that "everyone has the right to refuse" then ask for some sort of plan. ie: If patients declines turning and repostioning more than 2 days, then family meeting will be called to discuss other options for care" or something to that nature. There are lots of other legal guardianship type of things that state a patient can not refuse--but your company's attorney can go into more detail about that. Unfortunetely, when they don't get reimbursed due to pressure ulcers and the like is when they will have to start to address this, and it needs to come from top.
    I agree with this totally. I was a cna for 3 years and now a new lpn. And although your pts are refusing like previously stated they do not know what they are refusing although this can be construed as battery what is going on at your facility appears to be neglect There is no reason refusal or not to leave a pt sit in soiled briefs/bed EVER. Period. So u get more staff to help hange/turn them ect in case they become violent u are not commuting battery unless u are physically hurting them. I know it's a fine line but it seems as tho u will be more likely to lose your license (if the situation arose) for neglect opposed to battery. . And there is no reason a pt should get ulcers. They absolutely need to be cared for that is neglect I would be talking with don and management ASAP about these issues
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    It's situations like this that make me soooooo glad that my organization has established very strong Ethics Case Consultation committees in every one of our facilities. Members consist of clinical & non-clinical including at least one 'public' member - groups are facilitated by a chaplain or similarly qualified person. I have learned so much from these folks. Including the fact that just because someone is not 'competent' to exercise judgment about choice of chemotherapy vs. radiation, they certainly still have the capability of deciding if they want to be kept alive by artificial means - based on consideration of their life choices they have made over time to family members. I love our Ethics folks! Very committed to patient advocacy whenever legally possible.
    GrnTea and elkpark like this.
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    I know this is a late response, but it might help someone else. I am a retired lawyer now in nursing school. The answer to this is that the facility should encourage guardianship, sometimes called conservatorship, actions on the part of a responsible relative so they can then exercise the rights the now incapacitated patient no longer can. Thus, if the patient refuses, the trustee, or conservator, has the right to give legal permission to the treatment, action, etc. It is similar to a durable power of attorney, BUT only people with capacity to make decisions can execute a valid durable power of attorney, so those already incapacitated cannot, and that is why application to the court for guardianship is needed. I was just in a nursing home where they got the son to sign the durable power and then appoint himself as guardian...TOTALLY invalid. Most states also have provisions in the court for this process when there are no relatives. This does not address the problem of the patient saying you are trying to assassinate them, but legally, you can get the guardian to consent to care/meds, etc., so you can then do what is in the best interest of the patient without fear of violating their right of refusal.
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    Battery only requires an unlawful touching, it does not require that you be injured. Please see my post on this thread as to the legal answer to the question (but doesn't resolve the combativeness of the patient who has advanced dementia...though sometimes talking them through can help with that...sometimes not). My post addresses legal issues and how the nurse and facility can do what needs to be done for the client and protect themselves as well.
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    There's a fine line of providing necessary care and right to refuse with dementia pts. I have worked with moderate to severe dementia pts in a lock down unit for 5+ yrs. About 12 out of 30 are incapable of feeding themselves at all if that gives you an idea. We have several that despite every trick in the book, psych intervention, meds, etc still scream, curse, and hit staff during any type of cares. We can't let them sit in bm forever or never get washed bc of their behaviors. That doesn't mean we don't attempt to continue trying to distract, console, comfort, convince, etc. With refusals document document document. Everything you and CNAs tried, what the res did/stated. Ask for advice from your manager/supervisor and find out exactly what they want you to do in these situations.

    With constant med refusals find out what the requirements are where you practice to be able to conceal meds or get a Jarvis order. We have several that get their meds concealed in insure, ice cream, or oatmeal. We had one once we had to hide crushed meds under the yolk in a cut hard boiled egg. We have another that gets her one psych med concealed in candy.

    I know dementia pts are never easy, it takes special patience to care for them. Best of luck!
    zingyrocks likes this.
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    I really, really, really hate taking care of dementia patients for this reason. They are my least favorite patient population by a mile.

    My facility (hospital) allows dementia patients to refuse things. Had one a few months back refusing her labs. She was in renal failure and her potassium had been very high the day before. She refused lab when they came by. I tried to talk her into letting me draw blood but she refused me. The physician came by to talk to her and she still refused. She also thought we were all her relatives and she was at home... I wonder who exactly would have been sued if her potassium went so high that she had coded and died and we never drew labs on her. Would it be the phlebotomist? The physician? Me?

    They are just so scary to take care of. I could never work in LTC.
    Fiona59 likes this.
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    my facility policy was every refusal, RP notified, doccumentation, and physician / provider notified, docummented, careplanned, and follow up on continued refusals.........
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    Dementia nursing is full of a lot of grey areas, I used to work in a specialist unit that cared for those with neuro-cognitive disorders and I can fully understand the frustrations you have (esp. when families say "can't you just"). Dementia nursing is that area that isn't classed as mental health but you have most of the signs and symptoms that require some mental health support in order to protect both staff and patients. Where I used to work we used to have booklets called "All about me" from the Alzheimer's charity, something that would be filled out by friends or family so that we could learn more about the patient, what type of person they were... and could give us clues into what made them behave in certain manners (we used to have a patient who used to shuffle his hands every day at 5.30... turned out he used to work in a shop and 5.30 was when he used to count the days takings).With the medications, you can't force them to take them, but you can ask a mental health nurse practitioner to sign the paperwork for covert administration if it is deemed in their best interests (This was a god send and made things a lot easier). As for basic care provision you have to assess what is in the best interests of the patient and also what is safest for you (I personally almost lost teeth for trying to dress a skin tear wound, it wasn't worth it.) and clearly document your actions and attempts, pressure sores in some cases are unavoidable, due to nutrition, age, deterioration in health, so long as you have documented that you have done your best for this patient, thats all you can do.... you can't be accountable.

    Keep up the good care attitude, dementia nursing is so difficult! and I really respect anyone doing it
    Here.I.Stand and prnqday like this.


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