Depressed patient refuses positioning even though she is lying on her own bowel movement

allnurses Guide · Nov 17, 2017

By what criteria are you basing a lack of capacity? Simply being elderly and depressed does not imply a lack of capacity. Is she suffering from dementia or other cognitive decline. Capacity is a legal definition. Is she otherwise alert and oriented. Can she state that she understands the consequences and health risks of not being cleaned up. Was she adequately medicated for pain prior to the activity in question. A psych consult is probably in order.
Hppy

I am in no way saying that the patient in question should not be cleaned up and gentle force as in Therapeutic holds may be warranted - But I have found on more than one occasion when a patient like this refuses care there's more too it. Is the staff in question in a hurry and not paying attention to the patients facial and body language. Pain is usually a big issue with hip fracture patients and a lot of reassurance and a touch or pain medicine often gets the job done. When I worked with the elderly population I found several factors were involved. Patients feel infantilized, embarrassed, in pain etc.... A few gentle questions to figure out what the problem is can really make a difference.

Hppy

mmc51264, BSN, MSN, RN · Nov 17, 2017

ortho nurse here and it is an issue with A&O patients as well as the altered mental status pts. They have to be turned and def have to be cleaned. We use the chuck pad, make sure there is a pillow between legs and rolling onto injured/operative leg is less painful. We log roll as gently as possible and move as quickly and as efficiently as we can. It's doable :)

Ambersmom, BSN, RN · Nov 21, 2017

In geropsych, I encountered many patients like this. First off she does have the right to refuse. So in that instance, rather than forcing her against her will I would have a conversation and explain to her that I understand she is not feeling well, but she just had surgery and we can't allow her wound to become contaminated with her feces. I also would offer pain meds, and probably even request an order for a 1x dose if she wasnt due. Then I would tell that we are going to get her cleaned up, and I am going to gather extra people to help with turning, we will go as fast as we can to minimize discomfort. I'll make sure I have at least 2 other people, and then make sure we are gentle and fast. I make a point of letting her know exactly what we are doing at each step. I then document my conversation and actions. Amazingly, alot of these patients who didnt want care to begin with report feeling much better afterwards.

Medic/Nurse, BSN, RN · Nov 21, 2017

JI have consistently found that untreated pain and anxiety dramatically decrease patient cooperation. Treat those and you are already making therapeutic progress!

Fear is real too. Many (actually most all "sick") patients are afraid of something. If you don't know what it is - keep trying to figure it out. Try to address those fears and get support services involved. Instantly you have a better idea of how to proceed.

Patient despair (even family despair) can be a very real thing. Despair impairs most any and all therapy and will defeat lots of interventions. I've seen despair rip out ET tubes and lines of all kinds, it turns over beds, rips monitors off walls and it can pull a weapon. Despair screams or sulks and creates impossible to solve situations. Sometimes despair just sits and waits to die, it surrenders.

Despair is always bad. When faced with a patient in despair - seek reinforcements. Right away.

Sometimes, I think as nurses maybe we forget what an appropriate response to something is. Just want our work done. Check the boxes. Get the patient medicated/treated/changed, turned and progressing - a "good day". The patient needed to be progressed. But, OP to you the 80 year old was in an exceptional circumstance and you were rightly concerned, even though she may not have been having an inappropriate response. That is excellent observation from you at this point.

She may have not known that her daughter was "that sick" or maybe your patient had helped caregive for her daughter. I'm thinking an 80 year old patient lost a sub-60 year old daughter to cancer. Brutal. Was it a swift and brutal end or a long slog brutal end? Still that's damn young to die.

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It's okay for a parent of any age to be in despair over their child dying. I've made so many death notifications over the years I've lost count. All have been horrible in their own way. The worst one was when my 51 year old mother died suddenly of a PE (I busted in the door to her house to find that she had been dead about 12 hours) and I had to tell my nana that her only child (my mother) was dead. She watched me walk up the sidewalk (I had the ambo & fire truck wait 5 minutes before they came behind me and I went to forever destroy my precious nana's world) and she rushed to met me. I managed to catch her just before she fell to the ground screaming, wailing, pleading with me not to say it, "just don't tell me, don't let her be dead".

My nana who I adored more than anything, then had a near syncope and her heart rate dropped to a sub 30 and stayed there longer than I was comfy over. (Thankfully, I had asked my crews to provide "moral support" to me as I drove across town. Actually, my dispatch sent the entire fleet to my mom's house anyway - even though I only needed a couple of firemen to help the funeral home load her as I just could not do. I was too busy keeping my younger sister from throwing herself on mom's dead body and I had to keep my sis restrained, I had pulled her off my mother already twice forcibly and I did not have it in me to do it a third time.) Trust me, every moment for a week, including the funeral were excruciating. As much as I suffered, my nana's despair was the worst. It broke me. By the end of the week, I was even questioning my religion and wondered if there was a God.

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I always wondered why when young parent's lose a child, there seems to be so much sympathy. But when an older parent loses a child, I think there seems to be a societal shift of less sympathy. Just a thought. Why is the loss different? I think in some ways the loss gets magnified. All loss hurts.

Making her smile into trying compliance on changing her soiled linens, while well meaning (and I'm sure you are delightful) is not wrong, just likely not going to work. Being kind and considerate is always a good practice. Lead with compassion. Always lead with kindness and honesty. I understand the sentiment of cheer, but, this patient refusal prolly goes much deeper than it appears on the surface.

And just because she wanted to be "left alone" doesn't make her incompetent to make decisions. Also, many elderly folks post surgery have pain that is woefully under treated (old folks are fragile, etc. BS) - she might have been in enough "pain". May she was feeling isolated due to her change in circumstances. Maybe she was feeling sad, because she is appropriately sad. Like it or not, patients are not prisoners and do get to self direct.

THINK ABOUT THIS ----

What if this patient had been a young mother whose husband and three year old only child were killed in a car crash and she was status post surgery for open stabilization of pelvic fracture/femur fracture/hip fracture. And she had just soiled herself and was refusing to allow herself or bed to be changed?

How would you have changed things? What would you have said or done to try and change her mind? Why?

Something to think about and discuss.

:angel:

3ringnursing, BSN · Nov 21, 2017

That's sticky, but she can't be left to sit in her own waste either.

I guess this may help with perspective: if she wanted to tear her own eyes out and said it was her right would you allow her to? No, you wouldn't.

Patients have a right to certain autonomy, but there are also certain realms that are no option areas too. If the patient's choice is harmful to themselves or others then that option is taken off the table. Remaining in one's own waste certainly qualifies as harmful to one's self.

I hope this helps.

Here.I.Stand, BSN, RN · Nov 21, 2017

I would explain to her that lying in stool will cause what are essentially chemical burns, which are unlikely to be fatal (they could be if they progress to open sores, and she becomes septic.) I can't imagine how she must be feeling, but I would hate to compound her problems with chemical burns to the most sensitive area of her body.

It's true that if she were confused and trying to pull her lines out we could justifiably restrain her... but if she is of sound mind and saying "I am aware of the poo puddle under me and I don't care. DO NOT TOUCH ME," my concern with that is crossing the line into battery.

A psych consult is in order -- if nothing else, to get their recommendations. I don't see clear evidence of mental illness here, but psych staff are experts in assisting people in emotionally difficult places.

I love what Medic/Nurse said, and that story about their mom and nana was very heartbreaking. One of my uncles fell asleep at the wheel and died...he was in his early 20s and had just come home from Vietnam a week or two prior. So this would have been close to 50 yrs ago. For the rest of her 94-year life, my Grandma couldn't talk about him without tears in her eyes.

That woman was this pt's CHILD. She carried her for 9 months and gave birth to her. She smelled that delicious newborn baby smell, gave her her baths, got those first tastes of solid food in her own hair. She probably rocked and sung her to sleep. She probably kissed her boo-boos better...and wished she could do the same for her teenaged heartbreaks. This daughter probably bounced with delight when seeing your pt, fell asleep in her arms, picked huge bouquets of flowering weeds, and cried for her mama when she was scared.

That was her daughter. The natural order of things says that parents shouldn't outlive their children. I'm sure you meant well, but I wouldn't try to make her smile as much as demonstrate empathy for the very sad time that this is.

NICUMurse87, BSN, RN · Nov 22, 2017

Nobody else has said this, but I would see what the facilities policy is on such things. If it's like any hospital I've worked for, they should have a policy on almost anything you can think of. That would at least guide your thinking until you can get to the root of the issue.

cleback · Nov 22, 2017

I think you will be a good nurse If you're already thinking about these sticky situations. Although I agree that extremely emotional situations can make someone irrational, and then the duty to prevent further harm takes precedent, I think there were other interventions to try before arriving to that point.

First, treat her pain. That alone will make one unwilling to turn. The additional emotional pain can make the physical pain further intolerable.

Second, talk with her. Do more listening than talking. Is she scared? Wants alone time? Why exactly is she refusing? Usually, trating thr physical symtoms and listening to their concerns will help.

Others have said this but it really isn't appropriate to try to make her smile if she is grieving. Let her grieve instead and find some way to support her. Maybe she would appreciate a visit from the chaplain... If she's missing a funeral service by being in the hospital, maybe talk with the family and see if there is another way she can be involved.

Flo., BSN, RN · Nov 23, 2017

I used to be an ortho nurse. We had elderly patients s/p hip fx that would refuse to be cleaned often. Most times it was due to pain or anxiety. I would premedicate and we would go in as a team 3 or 4 of us and clean up the patient as fast as we could. One person held the patient's hand and talked the patient through the whole thing while the rest did the work.

Our floor never involved power of attorneys when patients refused to be cleaned. We just medicated and did it. I have never met one person that would prefer thier loved one sit in thier own stool rather than have us clean them up. And usually once it is done and the patient realizes that it was not as horrible as they anticipated, they are grateful. The big key here though is medicating the patient properly.

Munch · Nov 23, 2017

I used to be an ortho nurse. We had elderly patients s/p hip fx that would refuse to be cleaned often. Most times it was due to pain or anxiety. I would premedicate and we would go in as a team 3 or 4 of us and clean up the patient as fast as we could. One person held the patient's hand and talked the patient through the whole thing while the rest did the work.
Our floor never involved power of attorneys when patients refused to be cleaned. We just medicated and did it. I have never met one person that would prefer thier loved one sit in thier own stool rather than have us clean them up. And usually once it is done and the patient realizes that it was not as horrible as they anticipated, they are grateful. The big key here though is medicating the patient properly.

THIS..I think you would have more of a problem from the family/POA if you let the patient sit in her own waste. The patient is greiving..my father died when I was 17 and my uncle(my father's brother) died 2 weeks before him. They were 55 and 56 years old respectively. It absolutely destroyed my grandmother to lose two of her sons...my grandma had seen both of them through so much..they were both in Vietnam and made it through the other side to tell about it only to both succumb to cancer literally 2 weeks apart. Her apathy is probably due to her grief.

I am with FLO..medicate the patient(maybe get a one time PRN dose of ativan or valium if they don't have an anti-anxiety medication on board already) make sure her pain is taken care of and just get it done as quickly as possible. She already is depressed and in pain. Don't let her suffer the indignity of sitting in her own waste. I'm sure she will feel much better being cleaned up as well. The other patients will be grateful too..believe me! When I was in the hospital my roommate would go to the bathroom on herself all the time and it was not a pleasant experience. This was before I was a medical professional so I wasn't used to body fluids as I am now.

Orion81RN · Nov 25, 2017

Why would you need to get attorneys involved? This involves cleaning a patient who is laying in feces and urine. Attorneys will most certainly become involved when skin breakdown and infection occur.
To let somebody lay there in feces and urine who is depressed to begin with and says they don't want care which is probably due to the severe depression they are experiencing is inhumane if you ask me.

I think you need to look up what medical power of attorney is.

AgentBeast, BSN, RN · Nov 25, 2017

Patients will refuse all sorts of stuff. Patients have a right to refuse, however they must competently refuse. Determining competency is easy explain the risks and benefits of not performing something vs performing something and then have the patient repeat back what you told them in their own words. Most people that are refusing to get cleaned of their own excrement aren't competent to refuse to get cleaned up. As others have said it's worth investigating why someone is refusing something, but in cases such as refusing to get cleaned of excrement it isn't likely to be productive.