Patient with Dementia's Right to Refusal - page 2

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... Read More

  1. Visit  HouTx profile page
    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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  3. Visit  hunger4justice profile page
    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.
  4. Visit  hunger4justice profile page
    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.
  5. Visit  misstrinad profile page
    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.
  6. Visit  calivianya profile page
    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.
    Junebug903 and Fiona59 like this.
  7. Visit  sallyrnrrt profile page
    my facility policy was every refusal, RP notified, doccumentation, and physician / provider notified, docummented, careplanned, and follow up on continued refusals.........
  8. Visit  zingyrocks profile page
    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.
  9. Visit  GrnTea profile page
    Interesting book: Learning to Speak Alzheimer's, by Joanne Koenig Coste (2003). Great resource for anyone who deals c Alzheimer's disease in any context, personal, professional, or social.
    Debilpn23 likes this.
  10. Visit  elorne4647 profile page
    While I may be a relatively new nurse I have taken care of many patients with memory impairment as a unlicensed caregiver, CNA, nurse extern, and now an RN. From the sweet little grandma who flings four letter metaphors with fists of furry, to the less than appropriate ramblings of men with absolutely no filters. I've been hit, kicked, groped, and otherwise battered - and I have always respected my resident's right to refuse care in balance with their basic needs. I had a resident that screamed and swore and punched every single time we changed her. She was a big challenge for us as caregivers to meet her needs and not get pummeled in the process. Restraints, physical or chemical, are not the ideal route to go. Some people think they are the easiest. Having a multidisciplinary approach, getting to know your patients, and giving the individual the chance to make their voice heard while documenting, very specifically, every approach and redirect will not only help you and your healthcare team, but also CYA if something were to come up. If you can show the numerous, exhaustive steps taken to encourage compliance it will give you better ground to stand on than just saying, "Well we tried, over and over, we tried." With our patient mentioned above we found that distraction was the key, one CNA would hold her hands, gently, and talk to her about things she enjoyed and keep her distracted, while the other CNA performed cares. This enabled her to express her feelings, still get the cares she needed, and aside from a few well squeezed fingers, no CNAs were getting injured. From an RN standpoint I have a patient who routinely will refuse to take her oral medication. She may take her medications once a week at best. She may have no concept of what I am trying to give her, but she is not interested in taking them and in her state forcing the issue would not result in compliance. She may not understand what she is refusing, but she has the right, in my book at least, to tell me no. I make my attempt(s), and then document her refusal. The pills I am giving her aren't going to fix her, she isn't going to get better. If my forcing the issue is going to decrease her quality of life instead of increase it, is it right to force the issue? I don't think so and I know there are many out there who would disagree. When caring for a patient with a terminal diagnosis, which dementia is, quality of life over quantity. Will my insistence on cares/meds/treatment increase the patient's quality of life or just the quantity? Above all else keep the family on board and in the loop as well as management. Communication!
    snorkledorf, toomuchbaloney, GrnTea, and 1 other like this.

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