Ethical Dilemma: Is it ever ok to mislead a patient?

[RNjuice, ADN, RN]

I’m a new nurse working in rehabilitation and I have a resident with Parkinson’s and dementia. The resident also has wounds and has lost all mobility except in their arms (barely).

She takes her Parkinson’s medicine (Sinemet & Neupro patch) without issue, but consistently refuses all other meds (muscle relaxer, steroid, APAP, nerve pain med, and vitamins for supplementation and wound healing - a total of 8 pills every morning), stating that she takes too many pills (often arguing that we try to give her more than 8 at a time). She is not completely oriented to time/place, but she is always consistent regarding her medications.

Her family has tried to pressure me to administer her medicine without being forth-rite about it. For example, administering the meds in pudding without mentioning that there are pills in the pudding. The family wasn’t pleased that myself and the other staff comply with her refusals.

It seems wrong to ever be misleading to a patient or resident about the care that they are receiving and we know that our patients have a right to refuse. But what do you do when they potentially have altered mental status and their noncompliance puts their recovery in danger? (I’ve notified the provider already.) I’d be interested in hearing stories and advice from other nurses.

[Golden_RN, MSN]

I definitely think this goes beyond the bedside nurse. The MD, social worker & management should have a conference with the patient/family where they can come up with a plan, and this should be documented in the care plan.

I'd suggest to the provider to reschedule some to later in the day, particularly vitamins/supplements.

[Pepper The Cat, BSN, RN]

Hiding pills in food is a great way to get her to stop eating. I wouldn't eat anything you gave me if I found pills hidden in it.

Review her pills - does she really need all of them? And see if they can be spread out throughout the day rather than getting them all at once

[Corey Narry, MSN, RN, NP]

I agree that this should be handled in a multi-disciplinary approach and I'm actually surprised that it has not been addressed by your rehab team yet (MD, RN, Neuropsych, SW, etc). Is it possible that only the nurses have knowledge of it? While patients do have autonomy and have a right to refuse, there are considerations surrounding this patient's current level of competence to make decisions and what their expressed wishes were about their treatment before they lost the ability to make those decisions. There should be a meeting with the family and patient to address these.

[Sour Lemon]

Ethically, I'm okay with misleading patients if they're not competent (officially or not) and their comfort is at stake.

Example: I had a patient with a brain injury who was itching all over and refused to take atarax. The reason? ...because he was already "dead" and the doctor who prescribed the medication was "dead". He was red all over and miserable ...and he couldn't sleep because he couldn't stop scratching. He also loved pudding.
In a case where the patient is not suffering, I'd stay on the technical and legal side of things.

[JBMmom, MSN, NP]

If she is not completely oriented to time and situation I would be concerned that even if she is consistent, she is not able to make decisions that are in her best interests. I agree, though, that this is something that needs to be dealt with by more than just the bedside nurse. Does she complain of pain? If not, then the pain medications are likely not necessary and should be re-evaluated. If she does complain of pain, maybe changed the schedule so they're given at a different time would be less overwhelming to her. For wound healing, are you talking about a protein supplement? Maybe it could be changed to a liquid supplement that might not be objectionable to her. The focus should definitely change to education, but if the patient cannot make decisions in her best interest due to altered mental status, a healthcare proxy need to be in place to help guide treatment for the future.

[XB9S, BSN, MSN, EdD, RN, APN]

I realise it may not be helpful as I'm in the UK, it is interesting how other nationalities provide care for those with altered mental state. We have very clear laws that guide us (Mental Capacity Act) which direct us to undertake an assessment of her capacity relating to the decision, I.e. medication. If she lacks capacity then a MDT best interest discussion and decision can be made about the use of covert meds, considering her wishes for refusal balanced against the benefits of the medication.

[hppygr8ful, ASN, RN, EMT-I]

I feel it is unethical to mislead a patient in anyway except for very young children not capable of understanding. It is cruel to continue to flog a failing body in order to assuage some feeling of guilt or duty on the part of family members no matter how well meaning they may be, especially when there is no hope of recovery. I have found that many dementia patients still have capacity to make decisions on their own behalf with regard to certain aspects of their care. In the case described above a capacity exam is warranted as well as a consult for Hospice/Paliative care centered around comfort.

This is why I strongly encourage people to have these end of life discussions when they are still well and can tell people what they want when these decisions have to be made. All my wishes are in writing and in the hands of several people I trust. I have made it clear that if my wishes are not honored and there is something after death I will haunt them.

Hppy

[Guest219794]

1 hour ago, hppygr8ful said:

I feel it is unethical to mislead a patient in anyway except for very young children not capable of understanding.

Hppy

Curious- Why just very young children rather than anybody not capable of understanding?

To the OP- There are really 2 questions:

The one you asked-"Is it ever ok to mislead a patient?"

And the one you should have asked- "Is it ethical to lie to this patient.

From your description, this person is making a choice using logic that many might choose. You gave no information indicating an inability to make decisions. In that case, there is no question that it would be unethical to lie.

BTW- I make no distinction between overt lying and any deliberate effort to allow somebody believe something untrue. Just because you never fell asleep does not mean you get to say "no" when your spouse asks you if you are sleeping with somebody else.

As far as general ethics- While working overnight in the ICU, I got a call from the floor- "Can you come up and pretend to be a doctor?" I went up, and there was a LOL with dementia who, after refusing to take something, was told that the doctor thought to was really important to take the pill. She said that if the doctor told her that in person, she would take the pill. I am a guy. I walked into the room, and told her it was important that she take the pill. She believed I was the doc and took the pill.

I believe that by lying to her, I acted in her best interests.

I would do it again, though I accept that there is a good argument that it is unethical.

[litbitblack, ASN, RN]

Its not lying its redirecting....It took a long time for me to understand that when working with dementia and special needs residents. Where is this patient in her dementia journey? Yes putting them in pudding is a good way for her not to trust the nurses and then it will be difficult for you to encourage her to do anything. I would have the MD do a medication review and dc non essential medications. What wounds does she have? Will a drink supplement work in regards to taking the vitamins for wound healing. Does she really need the tylenol and the muscle relaxer? Maybe change the times of the essential medications and attempt at a different time. Maybe family can get her to take them ( they can be pretty persuasive lol). I have placed crushed pills in pudding ( whole pills don't really work because they know they are in there and will spit them out.) I have placed liquid medication in coffee or a favorite drink and it usually works. Chocolate syrup is usually pretty good and again that is if it crushed. I would first start again with medication review and a thorough look long term in deciding how much to push pills on her and risk what little cooperation she does give....

[dportal2006, ASN, RN]

If the patient is competent and aware of the medications, the reason why they are being administered and so forth then yes it is unethical to be hiding it from them. However if the patient has advance dementia and really does not have sound judgement then there is no hurting in a little white lie here and there. Just make sure that you are in fact reviewing the medications and they are necessary. Often times I find that some prescriptions for certain medications are weeks old and the patient does not even need them. If the patient has dementia and is non compliant then you can always crush the medications, mix it with a little pudding or so forth. If her problem is that you are giving too many medications at the same time then you can try spacing the medications out throughout the day.

[Wuzzie]

On 9/12/2019 at 11:08 AM, hppygr8ful said:

I feel it is unethical to mislead a patient in anyway except for very young children not capable of understanding.

I have a patient with dementia who has Sezary. We are giving her a monoclonal antibody to control her disease. It is not technically chemo in the traditional sense even though she has cancer and that is what we are treating. She keeps refusing it because she does not want to lose her hair (isn't going to happen) and she does not understand that it is for disease and symptom control. She refuses then consents, then refuses it again in the middle of the treatment then consents. She has no clear understanding of what we are doing and never will so even her consent isn't informed. Should we let her just die in agony because of this or use our best judgment to give her the care that she needs? Not being snarky but you have taken a hard line and I wonder just how hard it is. Her HPOA also has dementia.