Alert patients who refuse meds.

tvccrn, ASN, RN · Jun 13, 2010

If they are truly A & O x3 and the doctor has explained to them the risks and benefits? I reiterate those risks and benefits, ask if they understand what they are declining and if they indicate their understanding, I then chart that a discussion was held, what it entailed and that the patient still declined to take the meds.

Caffeine_IV · Jun 13, 2010

Thanks for your response. I forgot to note that I always chart that they refused and that they were strongly encouraged (or something similar) in the nurse's notes.

Davey Do · Jun 13, 2010

Amen. Once the patient makes an informed choice, and we have charted the results, we have done our jobs.

Too often I believe some nurses consider their endeavors a failure if they can't get a patient to take their meds as prescribed. Coercion attempts do happen. The desired end is often that percieved therapeutic by the nurse. However, providing information and allowing the patient to have a sense of autonomy is a successful endeavor, in and of itself.

POTR · Jun 13, 2010

At the same facility where I experienced my tale in the Pushing Dilaudid Thread, I have had a few stays for various things, always ending in the same ICU followed by a few more days on the same ward/floor in a different room. (Nice place)

During my stay previous to the incident mentioned in the other thread, I was out of icu and in a room for for a few days already. Ambulating rather nicely (10 laps of the square, 4 hallway ward, at least twice daily) I had already requested discontinuation of heparin two days prior, and had not been 'pressed' about it again since. The third or forth night in the room, I woke up to a male Nurse I had not met before jabbing my left arm, painfully I might add, with, you guessed it... Heparin.

After my complaint about this incident, I got pressed every shift change about my decision against heparin, except for the next night when I had the SAME NURSE, who spent every bedside visit apologizing and was so nervous I really worried for the care anyone else might be getting from them that night.

Now, as I said, I had been to the ward several times and almost every other Nurse on the floor knew me fairly well. So no problems with the assignment of the same Nurse, they knew I was only going to hold it against him long enough for him to get the point that he needed to be more careful, as well as respectful of patients rights.

Truth be told I was more annoyed with the constant 'pressing' and 'patient ed' on heparin following the incident, than the incident itself. Let's just say that I don't care if it's "Standard" for everyone post surgery to have heparin till they leave the facility. I am not "Standard," and once I am ambulating well, and I don't have any recognizable issues with the surgery site, I don't want ANY drugs I don't NEED. (I might also mention that I have Rx for Hydromorphone and methocarbamol, and I don't want them when I don't need them either.)

So, MHO would be:

1. Chart the refusal and any reasons for said refusal and move on.

and just as important, if not more so,

2. With any patient who already has a charted refusal, verify once asking for reasoning, chart appropriately and move on.

That doesn't seem to be too difficult a question.

BrnEyedGirl, BSN, MSN, RN, APRN · Jun 13, 2010

All you can do is educate and chart. I agree with you, most of the time I don't have the time to convince someone to take a needed med. Many folks seem to think that because they "had an neighbor who...." or the "read on Web MD...." that they somehow know more about what's best for them then the folks who studied for years in college,...go figure.

POTR · Jun 13, 2010

All you can do is educate and chart. ... Many folks seem to think ... that they somehow know more about what's best for them then the folks who studied for years in college,...go figure.

My first visit to that particular surgery wing I remained in ICU for 4 days with sinus tachycardia of 140 bpm and was experiencing anasarca by the second day to the point "my Nurse" nicknamed me "her Oompa Loompa." (If this ID's me to "my Nurse" drop me a line... I missed seeing you there the last couple of times I've been in for procedures.)

It took two days of begging and pleading on my part to keep her harassing the MD's to get them to allow removal of my foley. They kept saying it was protocol not to remove a foley as long as I was "tachy." And removal only happened after a bargain struck between the MDs and my Nurse that they would "allow" removal if my rate went below 110 and stayed there... I did everything I could to relax, meditate and slow my heart rate to the magic number, and she began to deflate the foley as soon as I got it down, not waiting to see if I could keep it there...

Guess what... the foley was out before she could finish deflation, and I urinated for a very long time.

What's the point of this?

I DO know better, and I totally despise MD's that will 'use' their degree and meandering, unproductive differential d/x of anything OTHER that what the Patient, or Nurse thinks may be going on, just to prove their degree means they know all and they can't be wrong/corrected...

And, in my book, derisive comments about any patient's education or path of knowledge would put the person that makes them in the same category as MD's that look down on Nurses because of their "lack" of education, and is completely inappropriate.

If the patient is mentally competent, has been counseled appropriately and still has reservations due to his/her experiences and outside knowledge, then so be it. It is THEIR decision to make based on THEIR VIEW of the risks involved in either accepting or not accepting a treatment or medication.

Meriwhen, ASN, BSN, MSN, RN · Jun 13, 2010

Not much you really can do. Unless they're court-ordered to take the medications (can't you tell I work in psych?), a patient has every right to refuse medication. Doesn't matter if they're AO3 or not. You can educate and you can encourage...but you can't force.

Document that you explained the risks of not taking the medication and that the patient is aware of these risks but still refused. Then you've done your part as well as CYA.

I educate them thoroughly the first time they refuse. I continue to offer the medication as the medication is scheduled (not every time I see the patient, just when I would have been giving them the med), and depending on whether they look receptive to teaching at med time, I may try to educate further. But I don't coerce or force at any time.

talaxandra · Jun 13, 2010

Hi POTR - I can't tell from your posts if you're a nurse as well as having inpatient experience. My reading of the OP is that the member was seeking advice on what to document, as well as how persuasive s/he ought to be, not whether or not the competent patient has a right to decline prescribed medication. For what it's worth, every patient is individual, special or non-standard, and differences of opinion between members of the health care team and patients don't necessarily mean that anyone is wrong or needs to be corrected. It is the case that experience informs education and decision making - in some cases that experience is an HCP who's seen innumerable patients with similar situations, and in others it's a patient or family member who's been through this before.

To the OP - the older I get the less inclined I am to persuade competent patients to take medications or otherwise follow recommendations (eg fluid restrictions). If you're aware of the rationale and possible consequences and want to go another way it's you who the consequences affect, and that makes you the best positioned to decide.

That said, I spent half an hour this evening talking with a new patient who's had a likely cortical infarct and is hypertensive about the benefits of an ACE inhibitor - he's reluctant to take medication, but is thinking about a bridging course while he makes lifestyle changes that will reduce his risk of a subsequent stroke, and which will reduce his risk of haemmorhagic transformation. I've given him literature about ACE inhibitors and stroke, and left it with him to decide.

SharonH, RN · Jun 13, 2010

I know they have the right to refuse of course but how much time do you spend encouraging them to take the meds or receive the IV antibiotics?

NONE.

SharonH, RN · Jun 13, 2010

If the patient is mentally competent, has been counseled appropriately and still has reservations due to his/her experiences and outside knowledge, then so be it. It is THEIR decision to make based on THEIR VIEW of the risks involved in either accepting or not accepting a treatment or medication.

Exactly.

I am 100% in favor of a patient's right to self-determination. If they have the facts and are competent to make a decision, then it is their choice even if there is a bad outcome as a result. To try to convince or coax them to do otherwise is almost disrespectful.

mamamerlee, LPN · Jun 13, 2010

I have had the opposite situation in my recent hospitaliztions - - begging for meds I knew I would need.

Because I have GERD, Sleep Apnea, and a herniated disc, I never lie flat. I have had 2 cardiac caths in the past year, and had to beg for pain meds for my back, and for extra antacids for the reflux. Never had chest pain, but was in agony from my back issues. Never had chest pain (yes, I know I repeated myself) but had a very burned esophagus from the reflux.

So the pendulum swings both ways.

Listen to your patients.

And for those who refuse? What else are they there for? Do they need to be in the hospital at all?