Duty of care

[marjoriemac, LPN]

Two incidents I would like to share with you guys to get some advice, both relate to our duty of care and that thin line between giving prescribed care and abuse.

1) Man with eye infection, prescribed eye drops, man will not open his eyes to allow me to put them in, he squeezes his eyes shut and fights with his fists. I record it in his drug kardex as refused. Nurse A says he needs them and she gets a carer to hold his eyes open whilst she inserts them. I think this is abuse, I would not like someone prising my eyes open whilst I lie in a state of terror even if it was for my own good. NB Eyes continuously slightly infected due to eyelashes turning inwards but this does not appear to bother him.

2) Medication controlled diabetic lady who we know eats biscuits and chocolate in her room, asks for a cake with her tea. I give her it, Nurse B says I shouldn't as she is diabetic. I feel she has made her choice by eating sweets etc in her room, she also asked me to give her a basic human need -food. The whole room of people were also getting this. Nurse B refused to give her a cake the other day and there was mayhem! She shouted and got herself worked up, refused to eat any food. What would you do?

I always feel we are there to help those who want to help themselves. In an age where we promote patient choice, how much choice do we give???

[Katnip, RN]

1. Is the patient competent? If so he has the right to refuse. If not, then it is appropriate to give the eye drops.

2. The woman may have made a choice, but you do not have to comply with it. Giving her cake is doing a grave disservice to her by promoting noncompliance. You know she is diabetic. You know she's not supposed to have these things. Let her get worked up. It's not your place to promote her disease. Cake is not a basic need. It's junk food. Now if her BS is fine with a cake or so now and then, then it would be ok once in a while.

It's time to talk with docs and family about a possible change of care. But any infection can spread and manage to turn itself into sepsis. And a diabetic can suffer terrible complications if uncontrolled.

[GingerSue]

about the cake - is there a dietitian who can arrange for a diabetic type cake? (my family member is diabetic - on oral antidiabetes med, and while in hospital there was white cake offered on the menu, and served several times/week (no icing)

[marjoriemac, LPN]

The gentleman to whom the eyedrops refers, is not able to verbally consent to any treatment. However I feel that saying just because he is not competent to give consent does not mean we should do anything we like when his fighting us off is very much not giving consent. What would other resident think if they saw two nurses holding down a frail old man and prising his eyes open.

The lady with diabetes has made her choice regarding her care. I once had a gentleman who only ate jam sandwiches and irn bru (a fizzy drink in Scotland). He was told he had diabetes and he had to stop eating them. Alternatives were provided and since he only ate jam sandwiches and fizzy juice, the alternatives were sugar free versions - but he could tell the difference and refused to eat them - so what were we to do, starve him just so his blood sugar would not go high? The women with diabetes has eaten sugary snacks since before she came to the home, her blood sugars are stable (probably due to her regular healthy meals) and her family even consent to her having cake (albeit their reasons are that she is in her late 80's and needs any comfort she can get). Dilemmas, dilemmas.

[morte, LPN, LVN]

years ago, perhaps 18-19....there was an op ed piece in the local paper.....should we do surgery on a person that was so demented he/she had no capacity to understand the pain he/she was being put through, or should he/she be kept comfortable till nature took its course.....i think your little old gent should be left alone....and the occ small peice of cake for a stable diabetic in her 80;s (her age does make a dif)...is no big deal...

[ktwlpn, LPN]

I deal with this type of problem every day.We have a late stage Alzheimer's resident that needs eye drops and we finally ordered them through the night-the nurse can get them on the inner canthus and then they go on and do the q 2 hr cleaning and turning.They roll right in.We also have a few non -compliant IDDM's-one is also morbidly obese.We have documented well and that's all we can do. Our care plan goals have really become more realistic.We are not shooting for the moon with blood sugars within the normal range.We want comfort-few to no instances of hypo/hyper glycemia,etc.We have gotten more liberal with diets in LTC in the past few years.We have a "no concentrated sweets" diet for our diabetics.They get a regular diet but instead of a large slice of pie or cake they'll get a small piece and seem satisfied.If they have access to money and can go off the unit to get snacks we can't stop them. When you are at the end of your life and in a nursing home what do you have left? The only thing they can control is their intake.I don't believe in berating them in any way-I consider that abuse...Nurse B has a problem-her way of handling the demented residents is not working and should be reported.It's so hard for that type of nurse because they are all about control....