concealed medicines?

nialloh, RN · Apr 3, 2005

This is a simple question and I almost feel silly asking about it, but it just won't seem to go away. At any given time it seems like I have at least one patient this applies to.
Can a nurse ever give medication to someone who won't accept it by way of concealing it in food? Does it make any difference if the patient is confused or demented?
My current example is absolutely and adamantly refuses any and all meds. Other staff report that the only way for the pt to accept meds is by crushing them and placing them into his food at mealtime. I don't feel comfortable doing that so I just offer repeatedly and sign as refused. Looking at the MARs at the end of the month shows that he always refused my meds and on very rare occasions the meds offered by other nurses. I am just a bit worried that it reflects poorly upon me. I don't want it to seem like I'm just too lazy to get him to take them. I have tried everything and he just won't do it. I really do believe the others are correct; he won't take them unless they're hidden.
Thanks for any input. :)

If the pt is AAO, yes, he can refuse any and all meds. If confused, (unless they were going to harm self/hit me) I wouldn't be comfortable forcing them to take them.

But then, I have the advantage of being an acute care nurse. I don't have them for long.

NorthER,RN · Apr 3, 2005

Hi Froggylegs - I believe that you are doing the right thing by listening to the patient and accepting his choice as being the one that matters. Indeed, rather than being paternalistic by just going ahead and doing whatever it is that other nurses may impose upon powerless patients, you might just be the only one that asks him about what he wants which makes you a :saint: .

However, please, please remember to document every single refusal and how you informed the doctor that the patient refused his medication. I've often had doctors tell me to do something which the patient has already refused and then had second thoughts once I told them that I will not lie to my patients. They are then more likely to speak to the patient and come up with alternatives. IMHO I think that behaviour like this helps to take away the powerlessness and hopelessness that people feel when things are just imposed on them. Thanks for being an advocate for your patients.

sassynurse78 · Apr 3, 2005

I am almost positive that you are not supposed to do this...if I remember correctly our facility got into trouble with the state over someone doing this years ago. It wasn't because of the meds in the food but the theory was if you put it in food how do you know they take all the med? Plus if you put it in say mash potatoes then you would have to stand there until all of the potatoes are gone. Besides that though I beleive that it is wrong. What if the pt. realizes what you are doing and then refuses to eat? I have had pts. that just did not like their meds crushed into applesauce or even ice cream, but we came up with a workable solution of crushing them and mixing them with chocolate syrup.

LPN1974, LPN · Apr 3, 2005

I work in MR/DDS and I currently have 2 people who refuse meds that no matter what I do I can't get them to take it.

One, if she refuses, she gets her Phenobarb in an injection, so I can take care of her that way.

But the other one is on meds for brittle bones, and Calcium, she's extremely overweight and a risk for fractures, so she needs her medicine.

But if I offer it to her she says, "no, no, I don't want it." So I came up with putting in a spoon of pudding and slipping up behind her, and just putting it in her mouth. That's the only way we can get her to take it. If you ask her if she wants it, or if she sees it coming, she's going to refuse. Now which is worse, her seeing it and refusing or surprising her and her getting her meds?

The point you have brought up is a good one. Now I'm wondering what our inspectors would say if they saw me doing that. I think I will talk to my DON about it.

A very good point you have brought up.

sassynurse78 · Apr 3, 2005

So I came up with putting in a spoon of pudding and slipping up behind her, and just putting it in her mouth. That's the only way we can get her to take it. If you ask her if she wants it, or if she sees it coming, she's going to refuse. Now which is worse, her seeing it and refusing or surprising her and her getting her meds?
The point you have brought up is a good one. Now I'm wondering what our inspectors would say if they saw me doing that. I think I will talk to my DON about it.
A very good point you have brought up.

I would think a spoonful of pudding would be fine...I believe it was the idea that the meds were put into an entire serving of food that was the problem. You can make sure an entire spoonful is completely taken, but not a food tray that then goes back to dietary, not too mention the confused pts, that might eat off others trays (I know gross but I have seen them do it lol)

sueb · Apr 3, 2005

If the patient is alert and oriented they absolutely have the right to refuse. However, if the patient is confused, disoriented with a diagnosis of dementia he/she is probably in no condition to make the decision that he/she doesn't want them. These patients do not always know what is best for them. We hide meds in food all the time. Just be sure that you are the one to give them. Do not let anyone else do it.

LPN_mn · Apr 3, 2005

I have been in LTC for almost 6 years. We were just recently visited by state and the question came up because one of our residents gets her meds with food at mealtime. We crush the meds put them in plastic med cup and put little med on spoon then get little bit of food to cover up med and give it. It works really well but when the state was going to cite us the only thing that saved our butts is that we actually got a Dr. order to do this. In Minnesota you are only allowed to mix meds with food if you have a Dr. order. The state does not consider pudding, applesauce, etc as food unless you are using what the resident has on his meal plate. If the resident is confused and has dementia then you may want to speak to the family and the Dr. to get an order to mix his meds with food.

FROGGYLEGS, LPN · Apr 3, 2005

Thanks for the advice on this. I really appreciate it.

Sassynurse, the points you made about the food are similar to what I seem to remember hearing forever ago in school. It seems like we were told not to because it could cause the pt to avoid eating or have a poor intake because of the taste. I don't recall it having ever been a topic in any inservices, etc since then.

The example does have a dx of dementia, but he is AAOx3. He is independent in all ADLs basically requiring only supervision. He appears to "check" his food and drink, presumably for medicine, before he will accept it.

The replies made me think of one other thing: we aren't supposed to pass any medicines in the dining room during meal time (in this state anyway).

I don't want to sneak his meds to him unless it is absolutely acceptable to do that. If I can't acknowledge that this is how he takes his medicine then I just can't risk the consequences. I will definitely be hounding the doctor for some kind of order.

Thanks again for the advice everyone.

LauraF, RN, ASN, CNA, LPN, RN · Apr 3, 2005

I just finished Mental Health nursing. They say never be deceitful like hiding it in their tray, unless 1. you have a doctors order. 2. They are not mental competant. You should probably call a team meeting, and discuss which meds are the necessary ones. I also had a patient like this in LTC, when I was working as an LPN. We would go over each day what each med is for. Then he would pick and chose. I would really encourage him to take the ones, like diabetic medications, and antihypertensives. I finally got the doctor to dc stuff like vitamins until we got his paranoid behavior under control.

LPN1974, LPN · Apr 3, 2005

I would think a spoonful of pudding would be fine...I believe it was the idea that the meds were put into an entire serving of food that was the problem. You can make sure an entire spoonful is completely taken, but not a food tray that then goes back to dietary, not too mention the confused pts, that might eat off others trays (I know gross but I have seen them do it lol)

Yes, I know that a spoonful of pudding is okay, but I was really concerned about the sneaking up behind this person and putting it in her mouth. If she sees me with the medicine she starts saying, "No, I don't want it." If I ask her to take it, she says "No."

That was my concern, if inspectors saw me sneaking up behind her and putting it in her mouth.

So what do I do? We know she needs it.

And I do have another resident who I have some trouble with trying to get him to take his.

{Now keep in mind, I work MR people.} This person takes his meds better AT the table. And what I do for him, is I put it in the spoon, {uncrushed pills} cover it with something sticky LIKE mashed potatoes, and just put the spoon back on his plate. I stay close but step back a few steps, and if he's in a good mood he will pick that spoon up and take it, pills and all. Then it's gone.

But I would never leave the area, not knowing if he took it, as you say, others might eat from his plate.

In this job I work in, we come up with numerous tricks to get these people to take their medications.

Where we are encountering so much trouble now, is the surveryors want each and every person to get their meds in private, and NOT at the table.

But with these type of people that is not possible with everyone. Some just won't cooperate and you have to be creative and come up with tricks to get them to take it. I guess some people who were not medically oriented might say we are deceiving them.

I look at it this way, if these people were not MR, then they would know that they needed their meds and would not be uncooperative.

It's kind of like in an emergency isn't it....."implied consent"?

elkpark · Apr 4, 2005

Yes, I know that a spoonful of pudding is okay, but I was really concerned about the sneaking up behind this person and putting it in her mouth. If she sees me with the medicine she starts saying, "No, I don't want it." If I ask her to take it, she says "No."
That was my concern, if inspectors saw me sneaking up behind her and putting it in her mouth.
So what do I do? We know she needs it.
And I do have another resident who I have some trouble with trying to get him to take his.
{Now keep in mind, I work MR people.} This person takes his meds better AT the table. And what I do for him, is I put it in the spoon, {uncrushed pills} cover it with something sticky LIKE mashed potatoes, and just put the spoon back on his plate. I stay close but step back a few steps, and if he's in a good mood he will pick that spoon up and take it, pills and all. Then it's gone.
But I would never leave the area, not knowing if he took it, as you say, others might eat from his plate.
In this job I work in, we come up with numerous tricks to get these people to take their medications.
Where we are encountering so much trouble now, is the surveryors want each and every person to get their meds in private, and NOT at the table.
But with these type of people that is not possible with everyone. Some just won't cooperate and you have to be creative and come up with tricks to get them to take it. I guess some people who were not medically oriented might say we are deceiving them.
I look at it this way, if these people were not MR, then they would know that they needed their meds and would not be uncooperative.
It's kind of like in an emergency isn't it....."implied consent"?

No, it's not like an emergency, and "implied consent" is when you hand someone the pill and say, "This is your blood pressure medicine" and the person then puts the pill into her/his mouth and swallows it ... The person didn't actually say, "Why, yes, I'm willing to take that medication," but the fact that s/he swallowed the pill indicates that s/he consents ...

I've worked for the last few years as a hospital surveyor/inspector for my state and the Feds. In my state, what many of y'all are talking about would be completely illegal, and it probably is in yours, too. Yes, if the state and/or Federal regulatory agencies found out, your facility would be in big trouble.

People do not automatically lose their legal right to refuse medications just because they are elderly or mentally retarded (or even because they are demented)! There's nothing wrong with crushing someone's medications into a spoonful of pudding or applesauce (assuming it's ok to crush the pills) because they don't like the taste or have trouble swallowing pills, but the person needs to be aware that the meds are in the pudding or applesauce and be willing to take them -- it's not ok to sneak meds into people (think about it -- would you think it was ok for people to medicate you without your knowledge and against your will?)

My state (and probably all states) has a legal mechanism for forcing medications on people against their will, and the state statute spells out the conditions that must be met. If those conditions have been met and the other requirements in the statute are followed, then it is legally permissible to medicate someone against her/his will. Otherwise you are breaking the law.

If someone has been adjudicated incompetent and has a court-appointed guardian, then it is the guardian who gives or withholds consent for medication (and everything else), and that is a different kettle of fish. But that means someone who has a legal guardian, not someone who is confused or difficult, and the family members are telling you they want you to do X, or its ok with them if you do X.