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

[RNjuice]

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.

[pmabraham, BSN, RN]

23 minutes ago, Wuzzie said:

Soooo, we should let the dementia patient suffer because they are incapable of giving consent because, let's face it, "informed consent" with dementia patients is an oxymoron.

Then you go to the healthcare POA before you do anything which is unethical. Paternalism/Maternalism in healthcare should always be questioned. Also, nonmaleficence (as an ethic) comes before beneficence for a reason. One can actually cause harm by thinking they know what's best and forgetting the patient and their POA (when the patient cannot make their own decisions) have the final say (not the healthcare provider/worker).

[Crash_Cart]

Please provide specific examples of "unethical" when working with the dementia population.

For example, is providing redirection or using similar techniques considered to be a misleading or deceptive "unethical" practice?

Pt. is asking off the wall questions about when the train is going to arrive on the nursing unit to pick them up and if you don't provide them with any honest answers to this question, is that "unethical?"

If they think you are their son, grand daughter or whatever, and if you don't correct and make them understand things differently, is that somehow misleading them and considered to be "unethical" ?

etc.. etc..

[Wuzzie]

8 minutes ago, pmabraham said:

Then you go to the healthcare POA before you do anything which is unethical. Paternalism/Maternalism in healthcare should always be questioned. Also, nonmaleficence (as an ethic) comes before beneficence for a reason. One can actually cause harm by thinking they know what's best and forgetting the patient and their POA (when the patient cannot make their own decisions) have the final say (not the healthcare provider/worker).

Geez, why didn't we think of that? SMDH. It's all well and good when everything works out that way but we have a situation now with a patient whose HPOA now has dementia and they have no other family. You might want to look up the concept of selective paternalism which definitely has its place in medicine. We are, after all, the experts and there is no way we are going to let a patient suffer unnecessarily because neither she nor her HPOA have the capacity to understand the risks of not treating.

[pmabraham, BSN, RN]

In my comments, I'm referring to the patient's bill of rights which includes the ability to refuse medications and treatments.

When it comes to dementia patients, please lookup validation therapy by Naomi Feil.

Wuzzle, which is why living wills are very important.

[Wuzzie]

So just to be clear, you think because my dementia patient with Sezary thinks that the monoclonal antibody infusion we give her to keep her skin from peeling off (increasing her risk for infection) and to stop the 24 hour a day intense itching is going to make her hair fall out so she routinely consents then changes her mind mid-infusion, then changes it back we should just not give it and let her suffer. Or we should start it then stop it and wait 5 minutes for her to change her mind again and restart it over and over?

Also, please stop talking to me like I'm an idiot. I've been a nurse for 3 decades and am well aware of things like Living Wills, HPOA's and ethics.

[pmabraham, BSN, RN]

As I shared, check with the POA... and unless the POA is legally removed as the POA, they are the POA. You are free to read into things, so if you are reading into the responses with a certain tone, that's your choice. I'm just sharing from a neutral perspective as well as one who cares about the patient bill of rights.

[Wuzzie]

3 minutes ago, pmabraham said:

I'm just sharing from a neutral perspective as well as one who cares about the patient bill of rights.

As if I don't. It must be nice to live in a cut and dry world but there are grey areas my friend whether you want to admit it or not.

4 minutes ago, pmabraham said:

You are free to read into things, so if you are reading into the responses with a certain tone, that's your choice.

It's not a tone. You were directly trying to school a seasoned nurse in how the process works, you're still doing it and I don't appreciate it. Also you have never actually answered my direct questions. Care to address them?

[pmabraham, BSN, RN]

Wuzzie, you are assuming in several areas. I was not trying to school anyone. Since you are a seasoned nurse, may I suggest start assessing more than assuming? ?

I work in hospice, so I know what gray is, but gray NEVER take away patient's rights. Now I'll end here, because you come across as having all the answers given your assumptions vs. assessing.

[Wuzzie]

Oh please. I asked you several direct questions and you have yet to answer them. I work with oncology patients and hospice/palliative care is a big part of it. I am involved in the decision making processes before the hospice team ever even knows the patient’s name. Regardless of what you think there is no glory in letting a patient suffer because they cannot understand the consequences of their decisions and I won’t let that happen. To do otherwise is inhumane.

[pmabraham, BSN, RN]

Yet without ethics, there lacks compassion and humanity. Now, since you've previously jumped to assumptions vs. assessing, let me be clear I'm not accusing anyone of anything. I'm sharing ethics matter and the patient bill of rights matter.

[Wuzzie]

Now who’s making assumptions? Never said you were accusing anybody of anything. But still, you haven’t answered my questions.

[traumaRUs, MSN, APRN]

STAFF NOTE - stop the back and forth please. Debate the topic, not the poster or leave the thread! Thanks.