Med Compliance

[PsychRN-Kris]

One of the things I hate to do is most is give an involuntary, second opinion injection of an anti-psychotic to a patient who is refusing their PO anti-psychotic. It's always a fight and ends with them being held down, which I can imagine is terrifying to the patient in their state of mind. I've had patient's refuse their PO daily for weeks.

So I'm always looking for new techniques, methods and tips for increasing med compliance. Please share if you have any!

[MrChicagoRN, RN]

What are their rights in your state?

Try discussing WHY they won't take their meds.

Denial of illness, side-effects, don't like feeling "normal" (gray).

What is it the patient wants to achieve? GO home, get a job, return to school, stay out of jail?

Talking these things through with the patient can often overcome their objections.

Even when totally psychotic patients can often be cooperative with someone who's developed a theraputic relationship.

If they're bouncing off the walls psychotic, ready to kill cause the voices say so, then the teaching may need to occur after the meds take effect. "Hey Bill, do you remember WHY the police brought you in 2 weeks ago?"

[PICURN74, ASN, RN]

I too am constantly worrying about this, check in your state RN law because patients often have the right to refuse medications even in PRN situations. personally I have never given a forced injection without a specific Dr's order stating it is against pt desire but have seen them given without them. Ideally PRNs would be given PO before the situation gets to the point of no return, I think we as nurses can be timid to give PRNs when pts are not yelling in the halls. If I think a PRN needs to be given IM then I try and talk to the patient about why I think they need the med and try to rely on the therapeutic relationships we try to build. However this is not always possible for a multitude of reasons, for scheduled meds that people are refusing I also often try and figure out why they don't want to take them, side effects, attention seeking, feeling they are better, etc. We use treatment teams where I work so if someone is regularly not taking meds we sit down as a team and try and find solutions, setting up both rewards (increase in level/privlidges for compliance) and consequences for non-compliance without reason. It can be tough but sometimes just asking nicely rather than demanding and asking a few minutes after they refuse and have had time to calm down work for me.

[nutribeat]

I agree that giving involuntary injections is a very distasteful task. Generally, I've not seen them given to patients unless they appear to be a threat to themselves or others. Reasoning with people who are overwhelmed with hallucinations, paranoid, and unable to separate reality from their hallucinations and delusions is not only unrealistic, but also unlikely to be successful. However, I have to admit, I was taught that it was illegal to administer medication without a patient's consent in any manner. That includes crushing pills and adding to food or drink. If this is correct, what recourse is there, when a patient is out of control and threatening or actually causing harm?

[MrChicagoRN, RN]

You need to know what your state law is.

First concern is safety. The patient's safety, the staff's safety, other patients' safety. That includes protection from physical harm, as well as protection from fear of physical harm.

Depending on the setting, that may mean isolating the patient, escorting them to a quiet area (call security or other staff to walk with you as needed), having a theraputic interaction that addresses the behavior, lay out the options...and the consequences. Are there any alternatives? If prns are refused, will they agree to take their next scheduled meds an hour early, with the antipsychotic as a liquid instead of pill?

[nutribeat]

Thanks, MrChicago.

And what consequences, if the medication is still refused and the behavior is not improving, would you suggest?

[MrChicagoRN, RN]

Thanks, MrChicago.

And what consequences, if the medication is still refused and the behavior is not improving, would you suggest?

It depends what the clinical setting is, and what the behavior is. There are oh so many variables.

But knowing what your GOAL is para mount:

In these cases, medication compliance obviously isn't a patient centered goal. It's a means to some other goal: Decreased agression, prevent self-injury, increased interaction, return to community, etc

A lot of times this needs to be brought to a staffing/care conference.

Sorry I'm not being more specific.

While not pertaining to medications, this article on alternatives to restraints may have some helpful information:

http://www.medscape.com/viewarticle/555686?src=mp