Ethical dilemma- Administering medications to patients with TBI

[MissJessP]

I work part-time at a brain injury facility and a patient of mine is ordered a suppository every other day for bowel protocol d/t chronic constipation. However, the patient rarely consents to this procedure and a member of nursing staff states to "just do it while the CNAs are preparing him for bed". This pt has a hx of agitation and aggression and telling him what is being done causes risks for the staff. However, doing it without first informing him is not ethical, at best. By practice, I refuse to deceive or withhold information from my patients unless the safety of themselves or others is at risk. Even then, I tell them what will be done so that they know what is being put into their bodies.

So tell me, nursing brothers and sisters...What would you do???

Thanks!

[MunoRN, RN]

There needs to be an assessment of the patient's competence to make medical decisions in order to answer your question. These are sometimes referred to as the 3 "magic questions" required to make your own decisions: Does the patient understand what we believe to wrong them, do they understand the purpose of the medication/test/procedure in question, and do they understand the risks of refusing this medication/test/procedure. They can be totally kooky, but so long as they meet these three criteria then they can refuse. If they can't meet these criteria, then that must be documented, and questions about tests/treatments/procedures/medications must be directed to a surrogate decision maker or in emergent situations medical necessity may be used.

I have seen situations where the solution is essentially 'lets wait until they can't refuse and then just do it', which is an illegal act.

[MissJessP]

Ok, let's go with this pt being incompetent of making own decisions. Family wants this procedure done. However, I can speak to pt and he can respond "no" or "I'll let you know when I want it," or "Not now". He can speak sentences, though they don't make sense at times, and he can express his feelings through verbal and physical acts. Because this is such an invasive procedure, I have a difficult time "just doing it" for prophylaxis. When I was hospice, I would do it for my patients who were in pain and could no longer speak for themselves or whose bowels were full, but they did not have the muscle strength to defecate. This pt is young and able, and I feel uneasy about performing an unnecessary procedure.

Thank you for bringing up the 3 magic questions. I am sure these are not routinely done. Many of our patients are obtunded and there are times when they are able to make decisions and other times they are not. Just because a person has a POA assigned does not necessarily mean that the decision making automatically defaults to them. In my assessment of this pt, he is not necessarily mentally competent, but very aware of his surroundings and what is being done to/for him. He can follow commands and speak fluent sentences (at times). It is such a fine line we walk.

Thank you, again, for your contribution. I greatly value it.

[nurse2033, MSN, RN]

Great question. I was intrigued until I read that family wants this done, now I'm outraged! Munro gives an excellent answer. I would however speak with the physician. They may not realize (?) the implications of the order. Can you convince them to at least make the order PRN for constipation? You could get the attention of management by writing an incident report each time you have to have a wrestling match to get this done. This is a patient and staff safety issue for a highly questionable medical benefit. Does the patient each their vegetables?

[litbitblack, ASN, RN]

How often is he requiring a supp? If it is pretty frequent and he takes po meds ok then I would ask for a routine laxative..

[offlabel]

Would he consent to an enema or digital stool reduction?

[Julius Seizure]

Ok, let's go with this pt being incompetent of making own decisions. Family wants this procedure done. However, I can speak to pt and he can respond "no" or "I'll let you know when I want it," or "Not now". He can speak sentences, though they don't make sense at times, and he can express his feelings through verbal and physical acts. Because this is such an invasive procedure, I have a difficult time "just doing it" for prophylaxis.

I want to start by saying that the scenario you have described is complex and that my input here is not going to answer what should be done. But I wanted to address the idea of a patient who can respond "no, I don't want that" and express his feelings, but is still not considered competent to make their medical decisions.

I work in pediatrics. I give suppositories to three-year-olds sometimes. They can do all those things, but they don't get to decide if they get the suppository or not.

That said, I think exploring other possibilities (as some others have mentioned) besides a daily suppository is a good idea.

[5150rn2]

Technically speaking a patient is not incompetent" until declared so. This can be incredibly frustrating when you know they aren't competent. But if they are saying no no no and are responding appropriately ( essentially) to instructions you really can't push it in my opinion. I have been in the position when a supervisor is trying to make me give someone a shot who doesn't want it. If after due diligence, teaching, persuading.. they say no, I say no. Then I chart like crazy. One is covers your behind and two, it serves to document behaviors/decisions that support pt is in fact incompetent.