Can a patient refuse PART of her medication dose?

Nurses Safety

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I work in a Juvenile Detention Center. One of my kids takes Trileptal 300mg...her bottle says she takes 2 at night, but she says that she takes 1 pill. She does not refuse her medications, just refuses to take 2 pills.

I have told her that it is her right to refuse her medications, and if she believes she only takes one pill at night, to refuse the other pill.

Meanwhile I have been trying to get ahold of the kid's doctor to clarify the order.

The evening LPN won't give her a partial dose. She called the Pharmacy last night and they told her that it was 'Prescription Fraud' to administer partial dosages, that the medication had to be administered exactly as prescribed or not at all.

I haven't been able to clarify this particular patient right. Anyone know??

nadjjaa, RN

Specializes in cardiac, ortho, med surg, oncology.
Why do people put questions up and then get angry when they get responses? :confused:

I didn't detect any anger in the OP's response. Frustration maybe but not hostility.

Patients do have the RIGHT to REFUSE all or part of their medication. Patient Bill of Rights anybody?! The nurse should talk to the patient and attempt to ascertain why the patient is refusing part of the dose (perhaps the side effects?), call the doctor and explain the situation and then let the doctor either change the dose or do as the doctor did in the case of the OP. As always document, document, document.

Whoever commented that giving a half dose constitutes prescription fraud is just wrong. Google prescription fraud. Moreover if you document you are not defrauding anybody.

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Specializes in Cardiac.

Whoever commented that giving a half dose constitutes prescription fraud is just wrong. Google prescription fraud. Moreover if you document you are not defrauding anybody.

The OP said that.

Look, the MAR says give X amount of drug. The pt can accept or refuse, but you can only GIVE what the MAR orders.

You cannot give more, you cannot give less. If the pt want's less, you get up and call the Dr and get the order changed. You do NOT make that decision for the pt. No matter what you think, that's called practicing medicine without a license.

At my hospital I'd get fired.

So if my pt has 40mg of lasix ordered for CHF, but they tell me they usually take 20 at home does that mean it's ok for me to give 20mg now? No. Either I give the whole dose, or give no dose. What if the pt wanted more? Is it ok for me to give more? What if they normally take 80mg at home?

I go by the MAR and bring it up with the Dr. But I don't decide on my own.

BTW, when pts refuse doses we still need to notify the Dr about it.

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I guess I'd be more worried about my CHF patient getting no Lasix or my young patient with seizures getting no trileptal than about nuances of interpretation.

I've often had a patient refuse some of his pills and the powers that be always supported that some were better than none. And we are always honest about it and document the heck out of it and have never been cited during survey.

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Specializes in cardiac, ortho, med surg, oncology.

You cannot give more, you cannot give less. If the pt want's less, you get up and call the Dr and get the order changed. You do NOT make that decision for the pt. No matter what you think, that's called practicing medicine without a license.

Ok you can get off your soapbox now. I stated as much when I said talk to the patient, ascertain why part of the dose is being refused and call the Dr. Now if the patient refuses part of a dose that is not the nurse making the decision it is the PATIENT exercising his/her rights. As we all know incorrect doses are at times ordered and by speaking with the patient and listening to their concerns you could potentially be helping to avoid a medication error.

Additionally, it was not the OP who called it prescription fraud, it was the pharmacy at her facility.

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Specializes in aged, palliative care, cardiac, agency,.

I have told her that it is her right to refuse her medications, and if she believes she only takes one pill at night, to refuse the other pill.

Meanwhile I have been trying to get ahold of the kid's doctor to clarify the order.

I dont have a problem with what you are doing so long as you document clearly on the medicaton chart and in the patient notes what you have done. Contacting the doctor is a must and should also be noted on the records.

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Specializes in Cardiac.
Ok you can get off your soapbox now. .

How mature.

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"You cannot give more, you cannot give less. If the pt want's less, you get up and call the Dr and get the order changed. You do NOT make that decision for the pt. No matter what you think, that's called practicing medicine without a license"

Here's a hypothetical question. I got curious with what was stated stated here. What if the patient is on a certain pill, let's say a Blood Pressure lowering medication called ABC. And he gets two ten mg pills of ABC (total dose is of course 20mg) as ordered. And so he takes one pill already, swallows it down, but refuses the other 10mg stating: "I refuse to take the other half, because at home I only take 10mg." But you know very well through the records that 10mg doesn't really bring his BP down, in fact that was the reason why the Dr. increased the dosage. What do you do then? Do you call the doctor and ask that the order be changed to just 10mg because he swallowed only 10mg? Any opinions? What would you do if you happen to be in this situation? Just asking.

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What if the patient is on a certain pill, let's say a Blood Pressure lowering medication called ABC. And he gets two ten mg pills of ABC (total dose is of course 20mg) as ordered. And so he takes one pill already, swallows it down, but refuses the other 10mg stating: "I refuse to take the other half, because at home I only take 10mg." But you know very well through the records that 10mg doesn't really bring his BP down, in fact that was the reason why the Dr. increased the dosage. What do you do then? Do you call the doctor and ask that the order be changed to just 10mg because he swallowed only 10mg? Any opinions? What would you do if you happen to be in this situation? Just asking.

That's an easy one. Document what was given and note in the MAR and the nursing notes the refusal and reason. Contact the doctor STAT if the pt is unstable and otherwise in the a.m. (if evening or NOC) if in a SNF.

It happens in LTC all the time and is neither shocking nor unexpected. I would imagine cardiacRN's setting is high acuity and a refusal is critical and dangerous, necessitating a different and immediate response.

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Specializes in Cardiac, ER.
"You cannot give more, you cannot give less. If the pt want's less, you get up and call the Dr and get the order changed. You do NOT make that decision for the pt. No matter what you think, that's called practicing medicine without a license"

I think the problem with this is that YOU aren't making a decision for the pt. The PT is making the decision. I agree that I can't just decide to cut a med dose in half,..although depending on the med and why I might at 0200 decide to give less and speak with the doc in the am,...for instance if I notice that at 2200 when the pt requested pain meds I gave 10mg of Morphine IV per Q4hr order,...the pt became difficult to arouse, respers dropped from 18 to 12 et became shallow,.O2 sats dropped from 99% ORA to 90%,.now at 0200 pt is fully awake et in pain,..it is in my scope of practice to start with 5mg Morphine et monitor response,.I would of course chart that I gave 5mg and why and then chart the response to the med,..I would then pass this on in report and leave a note to the doc,..I would think calling the doc at 0200 to cut this dose in half would be almost as irresponsible as just giving the 10mg because that's what the doc ordered!

It is my responsibility to monitor pt response to all meds,..it is my responsibilty to understand why the pt is taking the med, what it is for, how it works and what to expect in response to the med,....for instance IV KCL often burns,.I've had pt/family c/o "I'm having an allergic reaction to this IV!!" It is my job to teach the pt the difference between the common side effect of burning and an allergic reaction,.then it is my job to slow down the drip or dilute it so the pt can tolerate it,.if all that fails then I call the doc to come up with a different game plan.

We aren't trained monkeys folks! We are educated professionals and should act as such,.our pt deserve it and our docs expect it!

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Specializes in ER.

I think the key issue is whether the change in dose is nurse initiated or patient initiated. If the nurse just makes a decision they are practicing medicine. If the patient initiates it they are within their rights. In the second case you would notify the MD after the fact. In the first case the nurse should be calling the MD beforehand.

I also think that we can all come up with situations where we would just do something and let the doc know- like giving less morphine. The law is very clear but real life has shades of grey. If you know your doc and what they prefer it may make sense to call later. If the doc complains, or is unwilling to back you up you will be swinging in the wind.

I once gave plain Tylenol for pain instead of T#3 to a healthy postpartum patient at 3am, and the doc filed an incident report. (Crazy) But just because she was a dweeb I won't set the rules in concrete for reasonable docs and patients. It's a judgement call, and we shouldn't be shooting each other down. what flies in one facility won't in another. Some hospitals have ten family docs working 80 hour weeks, and some have a pool of med students and interns to take the calls, and night staff wouldn't recognize the attending if they fell over him. Different situations.

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Specializes in aged, palliative care, cardiac, agency,.
I think the key issue is whether the change in dose is nurse initiated or patient initiated. If the nurse just makes a decision they are practicing medicine. If the patient initiates it they are within their rights.

I think this nails it really clearly.

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Specializes in Critical care, tele, Medical-Surgical.

I work in acute care and would call the doctor at night if the patient refused all or part of an ordered medication.

I would document exactly what happened.

i have asked an irritated woken up physician to talk to the patient by telephone.

That patient took the medication after her doctor told her she needed the rest of the dose.

A different time a patient refused antihypertensive medications. i notified the doctor who told me, "Just wait. he will ask for it later. this guy likes to report nurses and threatens to sue the hospital over his refusal the take his pills. I expected this call."

And when i told him his doctor was notified he asked for his meds.

The facility should have a policy for such common events as a patient refusing medication.

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