How do you handle your A&Ox3 patients who don't want to take their meds?
Ex. HIV+ patients on antiretrovirals refusing d/t nausea even after zofran/phenergan ; pt with some type of infection refusing antibiotics because of the side effects.
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? Do you offer them again at a later interval?
I hate to be mean but on a very busy night I honestly do not have time to beg adult patients to take needed medication. I've dealt with these scenarios and the patients were very aware of the condition and informed by the doctors the importance of their treatment and I also followed with the same encouragement.
HIV+ patients on antiretrovirals refusing d/t nausea even after zofran/phenergan ; pt with some type of infection refusing antibiotics because of the side effects.
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? Do you offer them again at a later interval?
The patients are the ones who have to experience often unpleasant side effects, not me - they get to balance the benefits and drawbacks. It seems like the long-term benefits (eg delaying the progression to AIDS) would outweight the short-term issues (eg nausea/vomiting), but we've all acted in preference of our immediate wants (watching TV instead of exercising, fast food instead of cooking something better balanced, read a novel instead of writing a report) even when that conflicts with our long-term desires (improved fitness, lower fat intake, avoiding last minute rushing and panic). Just because my patients are in hospital doesn't mean they lose the ability to make those decisions for themselves.
But if they're in hospital solely for medications they decline, we will talk about whether they still need to be in hospital. And though I discuss the meds when I give them to the patient, my default position is that they're in hospital for intervention, so unless they say they don't want something I'll assume they're okay with it.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
back in the early 80s, i nearly lost a job once for not giving morphine 2 mg sc q 2 hours to a dying patient who refused it. i'd offer, he'd refuse. i'd chart it. the intern came in and told me to "just hold him down and give it to him." and when i refused that, he complained to my manager that i had refused to follow his orders. despite that experience, i still don't spend a whole lot of time trying to convince an alert and oriented patient to take their meds as ordered. just offer them, explain the rationale, then document the refusal and the teaching. now someone who is not oriented and trying to refuse their haldol is another story.
not much i can do about fluid restrictions if the family, once educated, continues to bring them big gulps. but i don't have to facilitate their noncompliance by bringing them extra fluid.
I had a similar situation with a teen CF patient, who did not want to even wake up (at 9am) or even consider taking meds. Mom sat at the beside, ignoring the spectacle her child was making, as she was surfing on Facebook and too busy there to help us to get her child up for her am meds. Arghh.
Asked Mom to help us to wake the child up and Mom replied that the child "wasn't a morning person" and that the child was only sleeping late because of being up until 2am talking on the phone.
It was an obvious lesson in very poor parenting. You could see why the child was in the hospital, as Mom didn't seem to care at all whether the child got the meds or not, and the child's condition showed that.
I won't beg anyone to take meds, as that can start to border on assault and/or battery, depending on how it is viewed. So, I reported this up the chain of command. The patient was discussed at the patient rounds, and the MD decided that her patients would have a three strikes and you are out rule. Meaning that the patients on her service would have two chances to mess up with their hospital schedule (IV meds, CPT, PT, and nutrition) and then on the third time, they could find somewhere else to go for care. Need I saw that this rule is now working like a charm?
Just as a side note, patients who refuse doses of HIV meds also risk becoming resistant to those meds, which may no longer work against his or her HIV virus.
I always tell pts, this regimen that you are on is the best for you with the least side effects and easiest dosing. If you become resistant to these medications, the next regimen may not be as friendly. If you don't feel you are ready to be on HIV medication talk with your provider. It's better to not be on it than to miss doses (ie, don't blow your options).
Document: pt educated on risk of developing resistance with eventual progression and death from AIDS, verbalized understanding.
I would also ask the pt. how he or she takes medications at home to tolerate them.
i've had few patients who could not tolerate one antibiotic due to side effects and physician changed to different antibiotic and patient completed the whole antibiotic therapy.
I had a similar situation with a teen CF patient, who did not want to even wake up (at 9am) or even consider taking meds. Mom sat at the beside, ignoring the spectacle her child was making, as she was surfing on Facebook and too busy there to help us to get her child up for her am meds. Arghh.
Asked Mom to help us to wake the child up and Mom replied that the child "wasn't a morning person" and that the child was only sleeping late because of being up until 2am talking on the phone.
My facility has patient who is a very young man (older teen) who stays up late every night playing video games and on his computer. He doesn't ever get up in the AM before noon. Our doc. simply ordered his daily meds and treatments for later. His first meal of the day is lunch and he gets a sandwich at midnight or so to compensate for not eating breakfast.
I have seen a big difference between patients (myself included) who have a collaborative relationship with their caregivers and those who don't. In the collaborative model, the patient (and/or the patient's parents) are considered part of the team, not just passive recipients of care. Their input matters.
The nurses and med students and docs and techs may have tons of expertise in their respective areas, but they understand that the patient brings something to the table that no one else can offer--knowledge of himself. Without that element included in the discussion, you can't help but end up with a cookie-cutter approach instead of a custom fit. A mitten instead of a glove.
One of my g-kids is a fine example of this. He was born with spina bifida and a Chiari II malformation. In his young life, he has had dozens of surgeries, from shunt revisions, to cranial decompression to major orthopedic procedures and many more. Most of the surgeries have taken place at our Children's Hospital, which is a teaching institution. Because his condition has system-wide ramifications, he often has residents and attendings from half a dozen or more specialties involved during the same admission.
My daughter is the gateway to her son. Over the years, she has stepped in many, many times and said no to various meds or procedures. This frustrates new students, residents and nurses to no end. "But it's part of our protocol," they will say. She has gotten to the point where she can rattle off the rationale for whatever is being discussed. Then she gives them her rationale. For this reason or that reason, her son doesn't fit the protocol for a child with just the one malady they are trying to address. She and the attendings have learned how to create and maintain the delicate balance his complex condition requires. If that means coloring outside the typical lines, so be it. The smart ones listen and usually agree. Or if they don't, they offer her new information and actually discuss the choices with her.
This kind of teamwork has earned her the respect of the chief residents who have worked with her over the years. She's been spot on in knowing when her son needs a neuro consult for a possible shunt problem, and she was even able to email pictures of an infected post-op incision site to one doc (a few of them have given her their cell phone numbers because they know she won't abuse the privilege) so they could bypass a four-to-six hour wait in the ER and go in as a direct admit.
I realize this account goes far beyond a discussion of med refusal. My point in sharing it is that collaborative care can make a big difference in patient/caregiver connection and keep the relationship from becoming adversarial. If, in addition to educating the patient, we also ask what they are thinking and what concerns they may have, we might gain valuable insight and see if there are any changes we could make or suggest that would overcome the objections.
Case in point, dh did not want to take a morning med that gave him occasional "fecal urgency" without much warning. He works outside and wears bib overalls and a heavy coat. I didn't realize he hadn't been taking the med until he told our doc. Together we decided he could take it before going to bed--ten steps from the bathroom--and he was fine with that.
A nurse who says, "I've given you the reason for taking this med. Can you tell me why you don't want to?" opens the door to communication. Even if the patient still doesn't take the med, at least someone listened to their thoughts.
If you've done the teaching and listened afterward, you can document whatever happens and know that you've done your job to the best of your ability.
At my LTC facility, any patient has the right to refuse their meds or treatment. I have patients who are awake but not able to communicate. I offer their meds ( usually crushed in applesauce or pudding) and they for the most part, take it. I have one patient that I have to break her pills in half for her and line them up on the table. She will pick them up and take them one at a time. Or she will throw them across the room. Most of my pts are not AAOx3...and if they refuse their meds, I do three things:
I wait a few minutes and try again.
Get another nurse or my nurse to try. (change of face...maybe I remind the pt of someone they didnt like.)
Try for a third time. If the 3rd time doesnt work, I just document it in my nurse's notes.
I have a pt who is AAOx3 who was refusing her scheduled Tlyenol. I asked her why on the second attempt and she stated "that it was doing no good so why bother?"
So, to the OP, my advice is all you can do is try and then document document document!!!
Agree 10000%!!! I've seen pts. angry and upset because they've had the same conversation with several different nurses. When given a good report, I'll already know the pt. does not want x,y,z. Then it is about approach of the pt.
"your previous nurse shared in report that you don't want ________, and she has updated the MD. We are waiting to hear back from the MD at this point. Your next dose is due now, did you want me to bring it? No? Is there anything else you can tell me that I can share with the MD about your concerns regarding this medication? What would you like to do instead?"
Some pts. will relax with this approach. Sometimes a tiny bit of extra information will be gleaned for the collaborative team. It may be a missunderstanding by the pt. about the effects. Could be one of about 100 different reasons, and pts. are not always forthcoming with those reasons.
I will push a bit harder if it's an antibiotic, but in the end an A&O pt. is making an informed choice.
"A nurse who says, "I've given you the reason for taking this med. Can you tell me why you don't want to?" opens the door to communication. Even if the patient still doesn't take the med, at least someone listened to their thoughts.
If you've done the teaching and listened afterward, you can document whatever happens and know that you've done your job to the best of your ability.
when i was started on keppra three years ago for seizure control, i soon discovered that if i took it as suggested by the pharmacutical company, i became terribly dizzy and nauseated. i realized if i took the hs dose as ordered and split the am dose in half and took half when i got up and the other half with lunch, it totally controlled the seizures and i had absolutely no dizziness or nausea at all.:)
when i was hospitalized for a bleeding meds-induced ucler, my neuro added my neuro meds to what my pcp had ordered. he wrote the order as i had been taking them.
problem was that a new nurse noticed that the ordered times deviated from what her drug program said.
she was adamant!! she would not give them as ordered, even after i explained why they had been ordered that way. i finally picked out what would have been my morning keppra dose at home, left the rest, and took the neurontin as it had been ordered. don't know what she told the pcp.
i wasn't trying to be difficult. i just knew i had tests scheduled that afternoon and preferred not to be dizzy or queasy. another nurse gave me the balance of the dose later.
sometimes the patient has a good reason for refusing, so ask.
Specializes in Emergency, Critical Care (CEN, CCRN).
Along similar lines, we occasionally get patients who refuse procedures. This happened to me most recently last night when I had a patient who tried to refuse a straight cath s/p head, neck and back trauma (we needed a urine preg prior to sending her for X-ray and CT, and the EC physician had ordered a urinalysis as well). In that case the patient was still a minor (albeit an old one at 17), so the mother consented for her, but the patient was a shrieking, gibbering wreck throughout her entire evaluation, citing overwhelming fear of hospitals in general and invasive procedures in particular. No amount of education would calm her down. She wound up being a social work consult for unrelated reasons, and I can only imagine what the poor MSW walked into...
When the patient is A&Ox3, legally competent and has a good reason to refuse (i.e. headache pt with negative head CT and no fever or neck pain declining lumbar puncture) - I'll educate the patient once and then inform the ordering ECP, and document the refusal. If the ECP wants it that badly, they can go in and talk to the patient. I'll do the same for mentally intact teenagers whose parents back their decision to refuse (i.e. 16-year-old with nausea declining IV access and requesting IM therapy instead - pt stated she was a known tough stick and didn't want sixteen pokes for a line, father agreed, ECP agreed, she got oral fluids and IM Phenergan and went home).
I document the refusal after attempting to find out the reasoning for it. If it persists to another med pass-I notify the MD. My idea is this, you don't wanna take your antibiotics etc...maybe you don't need to be in the hospital. Sometimes however, pts take meds at home on a different schedule than what we use in the hospital (God bless computer med pass) and feel that our schedule "isn't right"....LOL
Maybe why someone on anti-virals refuses is because of inadequate management of the side effects. Sometimes I think the poor management of the sides causes many people not to take them as ordered.
talaxandra
3,037 Posts
The patients are the ones who have to experience often unpleasant side effects, not me - they get to balance the benefits and drawbacks. It seems like the long-term benefits (eg delaying the progression to AIDS) would outweight the short-term issues (eg nausea/vomiting), but we've all acted in preference of our immediate wants (watching TV instead of exercising, fast food instead of cooking something better balanced, read a novel instead of writing a report) even when that conflicts with our long-term desires (improved fitness, lower fat intake, avoiding last minute rushing and panic). Just because my patients are in hospital doesn't mean they lose the ability to make those decisions for themselves.
But if they're in hospital solely for medications they decline, we will talk about whether they still need to be in hospital. And though I discuss the meds when I give them to the patient, my default position is that they're in hospital for intervention, so unless they say they don't want something I'll assume they're okay with it.