My client is going to college this fall, living in a dorm several hours away from home. Her 18th birthday is coming up and she becomes an adult with complete control over her own medical decisions. She has a form of MD, in a w/c, can only use her forearms, and needs a bipap at night. She and I have a good rapport and very recently she's divulged a lot to me about her views on drugs and alcohol. She's lived with overprotective parents and is looking forward to freedom and experimentation. She knows lots of MD kids through various social clubs and networks, and knows that when kids in college want to go out and drink, they just call the agency and cancel the nurse for the night, and get a friend to put them to bed.
I tell her flat out that as her nurse, I am obliged to tell her never, ever to do this. But then I tell her that I am not so stupid to think that she's going to listen to me (I mean, we ALL know what goes on in those dorms), so I took the opportunity to educate her on staying safe, like being sure she's placed on her side in case she vomits, use the buddy system but be careful who you trust, remember how vulnerable a pretty girl who cannot move can be, don't use opiates because they will slow down her breathing (something she has trouble with at night w/o bipap) and could kill her, etc. I'm hoping that if I give her enough details on how she's going to take extra precautions to protect herself, I can better illustrate WHY she should never cancel her nurse and she can make better decisions on her own. My comment on being a pretty girl who cannot defend herself did give her pause. I also told her that if she ever gets a police record, she would have to change her major because she needs a clean record for what she wants to do.
I didn't write about our conversation in my nurse's notes. The chart stays in their home and she reviews the notes daily, so I don't want to lose her trust in me and clam up. My #1 concern is her safety, not her friendship, and I'm hoping I could use this trust to understand her motives and be able to save her from herself. My services are through a national agency, and they'll be transferring her to another office near her college town. How shall I go about using this information wisely? Should I speak to my clinical manager first? My concern is, right now she lives in her parents' home and they would totally freak out, possibly pulling the plug on college all together, if they had any idea she wants to experiment. This has to be done the right way with respect to her adult status. Perhaps my office could document my concerns and the new office can be made aware of the potential for this client to make self-destructive decisions? If she's aware of everyone knowing what she wants to do, she can simply fire this agency and start up with a new one. How can this be approached delicately without turning this into a huge mess?
Mar 5, '11
Have a conversation with your clinical director and let her take it from there. If you are concerned, you might want to put something in writing in order to protect yourself. Your call. Or, your DOCS might ask you to write something.
Mar 6, '11
Wow, that is a tough one. One thing to note is that she hasn't done anything yet. Just because she is saying she will do this now doesn't mean she actually will. So telling her parents about it and risking them yanking the plug on college is not good.
I have 3 kids who went through college and I knew full well they would enjoy their new freedom in ways I would not approve. I told them the exact same things you did. They all said, "Oh Mom, don't worry, that won't happen to me." (Yeah right!) They somehow all made it through college intact and with no arrests and are living productive lives despite it all. Your client just wants to be normal despite her disability.
When she is an adult, she has the right to make any choice she wants if she is of sound mind. Even APS (at least in my town) does nothing if the client is of sound mind and chooses to do something self-destructive. You did all the right things by talking to her about safety and the danger she will put herself in.
Discussing this with your supervisor might shed some light on how to handle this. I'll be watching this with interest since this is a situation I've never seen/had in nursing and I'm interested in what everyone else has to say.