Did I miss something? (rant and need help)

LydiaNN · Aug 20, 2005

No link, just speculation, but could it be that since Mom said "do whatever you need to do to help him", that gives the doc authority to authorize the IM administration? My sense is that the doctor is interpreting that statement as a sort of proxy. Again, just speculation. I'm not even a psych nurse!

lucianne · Aug 21, 2005

I believe all patients have the right to refuse medication unless a court order is obtained. If the doctor wanted to use IM zyprexa instead of zydis, he should have written orders to discontinue the zydis. It is possible the patient would agree to the IM instead of a PO in some circumstances. We once had a psychotic patient who refused PO meds because he thought they were poisen but was perfectly willing to take IMs until he was less paranoid and willing to take his meds.

PMHNP10 · Aug 22, 2005

I believe all patients have the right to refuse medication unless a court order is obtained. If the doctor wanted to use IM zyprexa instead of zydis, he should have written orders to discontinue the zydis. It is possible the patient would agree to the IM instead of a PO in some circumstances. We once had a psychotic patient who refused PO meds because he thought they were poisen but was perfectly willing to take IMs until he was less paranoid and willing to take his meds.

This kid was perfectly willing to take PO. Of course he hasn't put up any fight with the IMs but IMHO there is a violation of his rights, and unfortunately noone other than us on the night shift have been the kid's advocate...we refuse to give the IM and if he needs a med for agitation, we call the on call and get a PO. It's quite frustrating. :angryfire

And now the kid is having some akathesia and the doc has charted it's because the nurses have not been giving him the IMs from the beginning and in a timely manner, therefore resulting in him having to be medicated by IM for a longer period of time. :angryfire :angryfire

Thunderwolf, MSN, RN · Aug 22, 2005

You may want to investigate the legal standing of a minor in your state. The legal parent of the minor is the legal guardian of that minor and may choose a particular treatment...even against the adolescents wishes. The same as an adult who has a legal guardian. In any case, the identified guardian needs to be kept in the loop during any event, especially during periods of patient decompensation. It is the guardian who makes the "informed" decision and who gives "consent". Totally agree, offering lesser invasive forms of meds needs to be front line as an option. But, sometimes, the option may not be relevant in acute crisis. So, to make a long story short...all new meds and med changes need to get the guardian's informed consent, signed, timed and dated. If it's telephone consent, two RNs need to hear the consent on the phone and both sign the consent form and informing the guardian to countersign it on the next visit. When it comes to a psychiatric crisis, maintaining safety of the patient and the safety of others is paramount. However, during these times, keep the guardian actively involved. He/she will say yeah or ney to the treatment regime...but, have it in writing. "General" consent to treatment, as you seem to indicate, could leave you generally open for legal problems if an untoward event should occur.

elkpark · Aug 22, 2005

You may want to investigate the legal standing of a minor in your state. The legal parent of the minor is the legal guardian of that minor and may choose a particular treatment...even against the adolescents wishes. The same as an adult who has a legal guardian. In any case, the identified guardian needs to be kept in the loop during any event, especially during periods of patient decompensation. It is the guardian who makes the "informed" decision and who gives "consent". Totally agree, offering lesser invasive forms of meds needs to be front line as an option. But, sometimes, the option may not be relevant in acute crisis. So, to make a long story short...all new meds and med changes need to get the guardian's informed consent, signed, timed and dated. If it's telephone consent, two RNs need to hear the consent on the phone and both sign the consent form and informing the guardian to countersign it on the next visit. When it comes to a psychiatric crisis, maintaining safety of the patient and the safety of others is paramount. However, during these times, keep the guardian actively involved. He/she will say yeah or ney to the treatment regime...but, have it in writing. "General" consent to treatment, as you seem to indicate, could leave you generally open for legal problems if an untoward event should occur.

Ditto. Unless your state law says otherwise (and v. few do), minors have no legal right to give or withhold consent for medication -- the consent belongs to the parent/guardian, and it is the parent/guardian from whom you need to get informed consent for medications. (In my state, "do whatever you need to do" would not constitute informed consent for medication ... :uhoh21: ) In most states, the law permits administration of medications without consent in an emergency situation, when a person is in immediate danger or harming self or others (or however the individual state has defined "emergency"), but you need to be clear on what your state law says and be sure that you are practicing accordingly, for your own protection.

PRNMEDS · Aug 25, 2005

At my hospital (I work with Adolescents) we only give IM if there is no other choice. If a patient (even if out of control, violent and/or requiring restraints) is willing to accept a PO PRN that is what they get. What is the point of giving IM if they can take it by mouth? The IM will work only slightly faster then the PO (especialy if liquid or Zydis).

As for Adolescent Rights - at least regarding meds - it is basicaly NO different then that of adults. You can't force them to take meds, unless they are a danger to self or others, in which case you then may need to force an IM. But in case you describe this does not apply since the kid is WILLING to take the PO PRN.

I think you should bring this to the director or Safe Care, the Medical Director or the Director of Nursing. Giving an IM is invasive and should be avoided, especialy if patient willing to take by mouth. Again - What is the benefit of IM rather then PO?

FeelGDRN · Sep 6, 2005

You dont need a link for good practice. I see things like this. First when dealing with that mental healt population you need to start with treatment interventions that dont violate their sense of control first. Offering the po gives them a chance to use their developing decision making skills and lets them feel that they had some control over the situation. Two, the decision to medicate a patient without them asking for it is done for their and others safety, and no other reason. Lastly doctors complain anyway, sounds like the one who was not there did the most complaining. It is a big challenge dealing with adolesents. Im an adult provider. Try the board of nursing ethics and scope of practice guidelines or psychiatric nursing association websites. Hope that was helpful.

CharlieRN · Sep 8, 2005

Sounds like you have a problem MD more than a problem patient. The doc failed to make his treatment plan explicit and is now blaming others for not carrying it out. If the po med is not to be used then it must be discontinued, or if it is to be used only under certain circumstances, then those need to be spelled out.

You may also have a shift to shift communications problem.

PMHNP10 · Sep 8, 2005

Sounds like you have a problem MD more than a problem patient. The doc failed to make his treatment plan explicit and is now blaming others for not carrying it out. If the po med is not to be used then it must be discontinued, or if it is to be used only under certain circumstances, then those need to be spelled out.
You may also have a shift to shift communications problem.

No, we (the NOC shift) knew why he wanted to use IMs because he charted in his progess notes how we weren't following orders and why he feels an only IM course of zyprexa was better for the patient. Our stance, though, was that the kid does have the right to not have a needle stuck in his hip Q8H. I mean, that's just common sense, and for a state to say otherwise is just unfortunate. Now initially perhaps he did require IM, but as time went on, IMs were not justified. I called 2 patient care advocates on the subject and both said we were in the right for offering the PO the first time (before it was dc'd) and the 2nd time after the PO was dc'd--I had to call the on call (who happened to be the psych director) and he gave the PO order without hesitaton.

Also to add something about the consent...it was initially signed on 8/16 by mom (or at least that's when the MD signed it). It was written for "zydis" and was checked off for the PO by the floor director after it was signed. After the 1st incident with the PO given and the doc's rant in his progress note about us not following orders, the floor director came back and marked IM on the same "zydis" consent. Then later when we as a shift refused to give the IMs, the director came in and wrote "PRN IM use discussed with mother". Also of note is that on the 21st the doc charted that he discussed this with the mother and she understood the reason for giving IMs. First off, I didn't know zydis came as an IM; and yes I'd contend that in court if need be. 2nd, the director really shouldn't be marking off stuff on a legal document as time goes by when needed. And 3rd, I thought mom knew why we were giving IMs long ago, but it wasn't until 5 day after the consent was signed that the doc chaarted that he discussed his reasoning with mom, who, btw, took him off the zydis in the first place because she thought it was too strong.

I could only hope this case would go to court; IMHO the whole situation was asinine.

Thunderwolf, MSN, RN · Sep 9, 2005

i can understand your frustration.

and what is that floor director thinking anyway?

new consent...new form...no changing the original document.

i'm glad you offered more info to enlighten.

the zydis preparation makes sense from med point of view.

ims offered as last resort.

parental adult of the child kept in the loop and informed each step of the way.

the doc is not the problem, but your director...from the way you explain it.

am i hearing you correctly?

wolfie

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zyprexa zydis

http://www.drugs.com/pdr/zyprexa_zydis_orally_disintegrating_tablets.html

zyprexa zydis (olanzapine orally disintegrating tablets) is intended for oral administration only.

each orally disintegrating tablet contains olanzapine equivalent to 5 mg (16 µmol), 10 mg (32 µmol), 15 mg (48 µmol) or 20 mg (64 µmol). it begins disintegrating in the mouth within seconds, allowing its contents to be subsequently swallowed with or without liquid. zyprexa zydis (olanzapine orally disintegrating tablets) also contains the following inactive ingredients: gelatin, mannitol, aspartame, sodium methyl paraben and sodium propyl paraben.

PMHNP10 · Sep 9, 2005

To us, it's both. The director for altering a legal document on more than one occasion, and the doc for charting in his progress note that we were not following orders by offerring the PO when in fact he hadn't dc'd it; and the fact after he dc'd the zydis he was limiting our options on the patient...PRN IMs or bust. I've never heard of a situation where you can just force IMs on a patient if they are totally willing to take the POs. Even if the pt is court ordered med admin (which is usually quite a process) the pt. has the right to be offered POs first, then forced IMs if refused--granted I've not been a RN for many moons, but this has been my experience on med floors, in CA state prison, in Fed psych VA facilities, and in private psych facilities between TX and CA--so that obviously leaves 48 other state laws/rules/regs.

Quite frankly I'd like to know what states allow forced IMs without offering POs cause I'd like to avoid them, but that's just MHO. Too much potential for problems forcing a needle in a psych patient when they don't want it; I don't want to stand before a judge explaining why I didn't offer the pt a less intrusive form of med and we inadvertently hit his vagus in the unnecessary struggle.