Alert patients who refuse meds.

[Caffeine_IV]

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.

What else can you do?

[kids]

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.

And this is the way it should be.

It makes things easier for the nurses if the patients all take their meds at the time rubber stamped on the MAR but adapting to the patient's habits and routines actually improves compliance.

[kids]

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,

Interesting. In my area due to mature minor doctrine we would NOT be able to obtain consent from the parent unless the teen was out of it. I'm assuming blood would have already been drawn on the patient at this stage, seems like a simpler route in your situation would have been to have lab do a blood test (it's part of our trauma panel).

[nrsang97, BSN, RN]

IF I have a pt that is refusing meds, I ask for a reason for refusal, educate and document refusal.

[Batman25]

All you can do is educate and be sure they understand. I'll ask if they have any questions or concerns that I can clear up. After that document the hell out of it. If I am tkaing over from a nurse where the patient has refused something I verify that in my initital assessment so I can document it and move on. It's in the best interest of the nurse and the patient.

[Caffeine_IV]

Thanks for the responses. I never try to force meds on a patient= or disrespect them at all. I just don't want to seem uncaring or lazy when I don't stay in the room 15+ minutes coaxing or something.

Honestly, this came about when I had a busy night recently where the patient's visitors were questioning my every move and then asking me if the antiretrovirals medicines were available in liquids or shots.

Then the following morning the mother basically said I didn't try hard enough to get him to take the medicine and I got very irritated.

[Redhead28]

Its their right. Right or wrong, no matter what I think. I educate, document and pass it on to the doctor or the next shift.

[shiccy]

For the nauseated patient, I will typically try a few times ... Sometimes a cracker helps with those folks, but I have been nauseated like that many times, and it's not a treat even THINKING about things like a huge antiretroviral going down my gullet.

As for the people that refuse anything else, ie- I work trauma, among others, and a standard care order is Senokot-s ii PO QHS because 1- they're ALL not walking as much as they always do, and 2- they're almost always getting narcs.

Here's my method of speaking with the patients when they decline them.

"You do realize what this is for, correct?" After they say yes, I REeducate and tell them AGAIN why it's important. If they continue to say they know that opiates have the side effects of constipation, and possible bowel obstruction, they usually stop me and say, "FINE!" (and take them to shut you up so they can go back to TV/conversation). I continue to inform them that the standard of care for bowel obstruction is a huge honkin' NG to LIWS, no food for DAYS, and possible other invasive proceedures (in case of bowel death) may ensue.

.....

Needless to say it's rare for my people to refuse Senokots. It does still happen, but I've seen the bowel obstruction route happen VERY fast, so ...

In terms of ATB, it depends on what they're refusing it for. I *ALWAYS* ask, "Do you mind if I ask the reasoning for not wanting the ATB?" They think you're being concerned, but that's ammo for charting. Reeducation of WHY it's important (pneumonia, etc) is done, and if they still don't want it, then document, inform the MD's, and move on.

Finally, be knowledgeable on these meds. Many times the reason ppl don't want the Senokots is because they don't want to be up all night pooping their brains out. ... Good thing those take >8 hours to work on a normal person, more for those that are sitting on their butts!

[*ac*]

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?

I have learned that there is no point at all in trying to wake a sleeping teenager in the morning - unless the med is very time sensitive, I just hold it till later. The fact that they were up very late is not necessarily bad parenting - remember teenagers are wired to be up late. Many of them really can't fight that tendency. This is why many high schools across the country are changing to later hours...

That the mom wouldn't help, well, lots of kids are in the hospital in some part d/t dysfunctional families. But whatever, who are we to judge? At least this mom was there - I take care of tons of kids who never have a visitor, much less a family member bedside.

[ZippyGBR, BSN, RN]

as others have said unless your patient is sectioned and the med is one which they can be forcibly given under their section there is little you can do if the patient is adamant. even if the patient is not fully alert forcing a med down them runs the risk of being seen as an assault. here is where good documentation and collaborative working both with your colleagues at the time and with the responsbile Consultant/ Attending Doctor is key

as good nurses opening a dialogue is the key , in the clinical area i currently work in we have some relatively long term patients ( SCI acute + rehab) and sometimes their prescribed meds don't always 'keep pace' with their progress especially analgesia and the meds for neuropathic pain , so a discussion ensues, in which the nurse can educate about things like the WHO analgesia ladder ( i.e. encouraging people to reduce their opiate dose rather than cut out their paracetamol and NSAID as their pain reduces - ceretain opiate side effects can be particularly bad for the SCI patient - constipation in someone with a neuropathic bowel .... ( bring on the picoloax and a Manual Evac) ...

[murphyle, BSN, RN]

Interesting. In my area due to mature minor doctrine we would NOT be able to obtain consent from the parent unless the teen was out of it. I'm assuming blood would have already been drawn on the patient at this stage, seems like a simpler route in your situation would have been to have lab do a blood test (it's part of our trauma panel).

Interesting, indeed. We don't have mature minor doctrine in this state, but again, if the teen is making a reasonable request and the parent backs it, we'll honor their wishes.

As for the need for a straight cath in this case, while we could have gotten the quant HCG from blood (it comes in your trauma panels? that's clever), we still needed urine for a UA. She'd taken some good shots to her back and flanks, and while we were reasonably certain she hadn't suffered ureteral/bladder/urethral trauma, we still needed to consider a kidney injury. Moreover, she also had history of bipolar disorder, and per the mother had gone off her meds two weeks previous. Frankly, she was one good outburst away from a primary cert when we got her, and as far as we were concerned wasn't competent to consent to anything, certed or not. Hence, we went with the mother for consent and got Psych and Social Work involved immediately.

[CharmantUn]

Has anyone tried/heard of motivational interviewing? It was a CEU/In service training topic at a VA hospital I volunteer for earlier this year. The heart of motivational interviewing is figuring out what the patient's ambivalence is towards making a change (i.e. losing weight, adhering to a drug regimen, etc.). I like it because it's asking a patient why they're not comfortable/ready to make a change rather than telling them what to do. Simply discussing ambivalence may plant the seeds of change better than begging for change.

[Zookeeper3]

Look I have a frequent flyer non compliant dialysis patient who demands a stack of saltines, a water picture and a picture of ice on the side to boot... you refuse, she demands the nursing supervisor and cals us all out on her right to refuse... I politely bring the dilaudid, zofran, phenergan, benadryl,,,,, with as much food and Ice as I can... she is barfing in a bucket demanding saltines and ice......

here, have it baby, puke it all up, just to do it all again because you demand it and the supervisor is more concerned with press gainey scores than your ICU stay which won't be paid for due to your non compliance.... have at it....

let me get you another picture of water as the house sup tells me to do...

We can NO LONGER REFUSE.... these idiots do this at home, you can't change them, why fight it? ... here have at it honey.