Breech of ethics

Pepper The Cat, BSN, RN · Mar 15, 2006

I am appalled. A person has a right to refuse medications. The nurse should respect that right. Would this nurse also force a Jehovah's Witness to take blood? Or Code a DNR? Why does she think she knows better than the patient? Because she "the Nurse"?? This type of nurse scares me.

DusktilDawn · Mar 15, 2006

A patient has the right to refuse medication. What the student should have done was ask the patient why they did not want this medication, and then educated the patient on why is was prescribed in the first place. If the patient still refused, then that would be their right. The student would then document about the patient refusing, reasons for refusing, health teaching done, and patient's insistance on still refusing.

When dealing with dementia, it is still important to ensure the patient's right to make decisions is not violated. Offer explanations and assistance as necessary. Also speaking to family or caregivers and enlisting their help with medication compliance. You can refer to legal counsel if a patient's competency is in question and guardianship is needed.

VickyRN, MSN, DNP, RN · Mar 15, 2006

i'm an rn student one month away from graduation. very recently a classmate of mine told me that while in clinical they have done the following:
they're in a patient's room with morning meds. the patient refuses a med, saying they just don't want to take it. the student replies, "fine, but i have others here that you need to take..." such as their abx etc... the patient indicates compliance and the student proceeds to open up all their meds (including the one(s) they have refused), place them in a cup, and then hand this cup to the patient. the patient takes all the meds not know that the one(s) they have refused are among them.
i was pretty appalled when i heard this. to me it seems like a violation of the patient's right to make their own health care decisions.
your thoughts? does it matter what the med is, what the reason is, or whether or not the person has dementia?

you are so right to be concerned - this is definitely a breach of ethics. this is nursing 101, a basic tenet of patient rights. i have also found that when a patient questions a medication, it should always be taken seriously. often the patient's concerns are validated by the fact that it is a wrong medication/ dose or an undocumented adverse reaction. this sends up red flags about your classmate's moral character, as well as his/her future safety as a nurse. are you able to report this anonymously to your instructor?

mariedoreen · Mar 15, 2006

you are so right to be concerned - this is definitely a breach of ethics. this is nursing 101, a basic tenet of patient rights. i have also found that when a patient questions a medication, it should always be taken seriously. often the patient's concerns are validated by the fact that it is a wrong medication/ dose or an undocumented adverse reaction. this sends up red flags about your classmate's moral character, as well as his/her future safety as a nurse. are you able to report this anonymously to your instructor?

thank you. i think you all have simply confirmed what i already really knew, but am somewhat afraid to address. i didn't realize it would be so difficult for me to report a breach of ethics. primarily because i really can't do it anonymously. the student is going to know it was me, i'm the only one she told. and that that seems to matter is also a suprise to me, what does that say about my character?

the above concern you raised about wrong medication also occurred w/ this student. primarily because the patient had a dx of dementia and (i believe) the student was already in the habit of discounting what patients with dementia say. when this pt indicated that the med was not hers, this student didn't believe her and proceeded. it turned out she gave her someone else's morning meds. the school does know about this incident.

time to bite the bullet and talk to the instructor... thank you again.

gr8rnpjt, RN · Mar 15, 2006

Thank you.
Time to bite the bullet and talk to the instructor... Thank you again.

This sounds like a toxic situation for this girl's patients. Something needs to be done. Maybe the instructor can take this out of your hands by bringing up the subject of ethics and describe the situation to the class. She can ask the class what they think of the situation and what they should do. This girl would learn that her thinking is very skewed and realize she needs to change her ways. It is frightening that a patient was given the wrong meds and the hospital did not know.

DaFreak71 · Mar 15, 2006

I agree that it was most inappropriate for the student to deceive the patient by slipping him the medication he voiced refusal to take. This student needs to understand the concept of a patients right to refuse, reporting this student is probably the only way to ensure that he/she gets the appropriate counseling they need on this topic.

With that said, I wonder why it is that most times on this board when someone does something questionable, their morals and character immediately come under attack. Is it not within the realm of possibility that this student has a great character and good morals, but is misunderstanding the reasons why it's ok for a patient to refuse a med? If I may play devils advocate for a moment, isn't it plausible that the student nurse understood the importance of the patient receiving the medication and felt that by tricking the patient into taking it, it was serving a greater good?

Don't we all make judgement calls in our lives that fall short of perfection? I know I sure do. But if we constantly call into question a persons morals and character, doesn't that just leave us wide open for the same

accusations when we do something that the majority doesn't agree with?

I have dealt with this very situation in my personal life. My husband and I were taking care of his father who has early alzheimers. He did not want to take his Aricept because he felt it was too expensive. Since my husband and I also took care of his finances, we knew that it was well within his budget to afford his medications. So we continued to purchase it and we continued to give it to him, despite the fact that he did not want it. The danger of giving it to him was that it would make him angry if he found out, the danger of not giving it to him was that his cognitive abilities would continue to detiorate and he would eventually end up in an assisted living center. If he thought Aricept was expensive, he would have really had a problem with how much assisted living costs.

I firmly believe in a patients right to refuse their medication, but there are situations that create a grey area. If your patient was drug seeking and the doctor ordered a placebo (something I vehemently disagree with), isn't that the same grey area as giving the correct med to a person who doesn't want it? Both are dishonest. I disagree with the use of placebos for a patient who is drug seeking because it ignores the root problem, drug addiction. Drug addiction should be treated, not swept under the rug by giving something that the patient perceives to be a narcotic in place of saline. This doesn't address the underlying problem and I think it's indicative of our desire to avoid conflict rather than deal with it. But that's just my opinion.

I just don't get where a person can be automatically labeled as having a poor character or morals based on one persons post about an isolated incident. Shouldn't our morals/character be judged holistically instead of situationally?

Adri

DaFreak71 · Mar 15, 2006

Thank you. I think you all have simply confirmed what I already really knew, but am somewhat afraid to address. I didn't realize it would be so difficult for me to report a breach of ethics. Primarily because I really can't do it anonymously. The student is going to know it was me, I'm the only one she told. And that that seems to matter is also a suprise to me, what does that say about my character?
Don't be so hard on yourself. It's normal to feel apprehensive about reporting someone. I think it would be more out of the norm to not feel that way to some degree, as long as in the end you did the right thing. And only you can judge that. Feeling nervous about reporting a student tells me that you don't gratuitously run to the instructor everytime someone makes a mistake, that you consider the outcomes and the reasons behind your behavior before you act. Even if the reasons are what some would call selfish (not wanting to be discovered that it was you who reported it) it is certainly human and certainly understandable. I'll bet your character is just fine.
Adri

Antikigirl, ASN, RN · Mar 15, 2006

Yep, it is unethical to administer medications or treatments a patient has declined. So you are right to question this action!

Me personally, I would talk with the fellow student and discuss this in a positive manner of concern for the student and patient. Discuss your uneasiness with that action, and definately tell them "I believe if you are caught this can be trouble for you...and I don't want you to get into trouble".

I have seen the bad side of forcing meds or tricking patients! I knew a nurse that did that very thing (talked the patient into taking a med and putting in the others)...but the patient was pretty zonked out from pain meds and couldn't relay that she was allergic to the antibiotic and aspirin that was prescribed in hospital...she was going to change this when she spoke to her MD. Sadly she broke out in hives and itched like no tomorrow, and nothing could bring that itch down for several hours. So here is this poor lady in itching agony in bed and painful! If the nurse had complied with the refusal...things would have been much better! Instead no one knew why she had hives and stoped all meds = pain!!! (post surgery, abdominal) till they could find the culprit...poor thing!

I had a patient who was declining any glucose sticks for her CBG test...but wouldn't tell me why at all! All nurses including myself assumed she was being noncompliant (she was nasty as is) but I was the only one that wouldn't do it because she declined! The poor dear when nutty and screamed and threw hissy fits all the time. Then I was her nurse again...asked her if she wished the CBG test, she declined again. She was slightly demented but I still did not give. Because she felt she could trust me I found out she was HIV positive and was afraid of spreading it to us nurses! I educated her about HIV, and thanked her for her concern (always validate a concern, even if it seems silly...then redirect). The poor woman was scared to death she was spreading AIDS around...no wonder she was so upset (but dementia and wanting to keep that to herself got in the way)...but thankfully she trusted me enough to let me know...all because I respected her rights to refuse (informed refusal that is...I did inform the patient about the test, reasons, risks...etc before accepting the refusal and documented that!).

Stick to your guns...you are right on the money!

rn/writer, RN · Mar 15, 2006

i wonder why it is that most times on this board when someone does something questionable, their morals and character immediately come under attack. adri

vickirn posted:

this sends up red flags about your classmate's moral character, as well as his/her future safety as a nurse.

raising a red flag is not the same as attacking. it is merely noting that something bears watching.

when a person does something questionable, seems like it's worth questioning. it could be, as you suggested, that the nurse simply misunderstood the situation. it could be more. that's why it bears watching.

in this particular case, morals came up because this is situation where ethics come into play. it doesn't appear to be a case of misinformation, but rather one of values. that said, someone (the instructor) needs to dig a little deeper and determine if this soon-to-be-grad understands her ethical obligations and is willing to abide by them.

i just don't get where a person can be automatically labeled as having a poor character or morals based on one persons post about an isolated incident. shouldn't our morals/character be judged holistically instead of situationally?

no one labeled her, just said her actions raised questions. the way to judge holistically is to use that red flad as a reminder to keep an eye out and gather more information.

questioning a matter isn't the same as condemning it. in fact, questioning can have the opposite effect--that of clearing confusion and vindicating the person or event being scrutinized.

Antikigirl, ASN, RN · Mar 15, 2006

RN writer..thank you..that is why I put up in my post actually discussing this first before blowing whistles! It may be something that student watched another RN do, or something she may have learned that was okay according to the time she learned it!

I actually was chastised by nurses for not doing the CBG for the lady I discussed. I mean the actual words were "why didn't you make her"...I was flabergasted! I told that RN that you CAN'T force treatments in this day and age...and to never EVER question my rational for doing things before you read my nursing notes (everything was in there in detail and quoting the patients right to refuse)!

Did I blow the whistle on anyone...no! I calmly discussed this with the individuals and was very cool and proactive for both parties...that won! Sometimes we need a little education, reeducation, or reminder...and that is a better way to go then to be a whistle blower without considering the situation in full (within reason of course...sometimes you have to blow the whistle right away no matter what!).

Yes she breached the patients rights, I am pretty sure if we all look back we all did at one time or another (sometimes unknowingly). I have a feeling redirection or discussion would be appreciated before assuming the worse case scenero and blowing the whistle~!

cammie · Mar 15, 2006

re breech of ethics.

i work in England and boy is that a breech of ethics. i agree with the sentiments of the others reply. i also want to ask why were the meds opened up. this puts the student in even more danger because if this is against the licence for the drug the adverse effects for the patient could be catastrophic and the student can be legally liable for any injury to the patient. she can also be at risk from inhaling drug dust.