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.
In my comments, I'm referring to the patient's bill of rights which includes the ability to refuse medications and treatments.
Dementia pt's don't "refuse" medications because they are confused and they simply don't know what it is you are doing, or what is it you are giving them exactly.
Suggesting there is some way to make them understand, when the reality of the matter is, this isn't even remotely possible to do in the first place because of their cognitive deficit medical condition. That is to say, it's simply not possible to make them understand.
However, I still fail to understand where the so called ethical dilemma situation exists exactly. All you are trying to do is provide them with the best medical treatment and personal care possible. That's all that should really matter at the end of the day isn't it?
Even though the cognitive impaired patient may not understand what I am doing, or what medication I am giving to them exactly, I would certainly never do anything that causes any harm to them, end of story!
I suspect those who have no previous experience working with the dementia population have no way of understanding the reality of the situation.
While I do sincerely support and appreciate the sentiment of ensuring the principles of ethical nursing practice is upheld, maintained and followed, you need to understand the world of nursing isn't exactly a matter of seeing everything in simple black and white either.
Medications are no different than if a resident stops eating because of advanced dementia. It is the natural course of the disease and to me, there is virtually zero quality of life when they get that bad.
If they refuse, they refuse. If not taking meds leads to their death, that is the natural order of life.
The topic seems to have touched a nerve, which is why I thought to bring it up here in the first place.
As a new nurse, I don't have the instinct, wisdom, or experience that some of my peers possess. Nevertheless, I am sometimes placed in the same situations as my peers and have no choice but to approach each situation from my own perspective - which is as a novice nurse who is dealing with everything for either the first time or the second time since reading about it in a book for perhaps a week some years ago in nursing school.
There are some situations where I can simply study up on a patient's diagnoses on my own time to refresh my memory or to learn about what nursing considerations are appropriate, and I do that.
But this is indeed a gray area. It is absolutely open for debate about what consent means when you have a patient who arguably does not possess the level of cognition necessary to make decisions regarding their own care.
For example, we don't "allow" people to commit suicide. But I recently had a patient whose wife died. Grieving, the patient made a decision to stop taking his antibiotics until he became septic. I sent him away to the hospital, where I later learned that he was placed on hospice and passed away a week or two later. Prior to his being sent away, psych and the care team were both aware and involved.
One of the responses referenced a law in the UK that helped to clarify what should be done in the event that a patient does not possess the cognitive ability to make decisions regarding their own care. As I practice in the United States, this legal mechanism does not apply in my situation. That said, given the unclear nature of my initial question as evidenced by the passionate and varied discussion which followed, it seems like a standard that we can all follow would be helpful so that the decision doesn't fall upon a nurse who is new to the practice and only has about 10 minutes to spend with that patient per day in an 8 hour shift to begin with. I don't mean this as a complaint, but simply that the cumulative knowledge of many experienced healthcare professionals deciding upon a standard of care that novices like myself can follow would benefit the patient more than it would benefit me.
As I work in a Rehabilitative setting, many have suggested that I involve the patient's care team. Members of the care team have been notified, but aside from experimenting with changing the resident's medications and supplements, the specific issue of medication concealment or the resident's right to refuse have not been specifically addressed. As my facility has been in a transition process, there hasn't been a hierarchy of nurses to address the issue with, either. I will continue to pursue the issue as the situation evolves and, once again, I very much appreciate everyone taking the time to share their different perspectives on the issue.
There are valid points on both sides of this argument, and by referring to it as an "ethical dilemma," I'm not trying to assign judgement upon anyone for making the decisions they thought were best in their particular cases. It's simply a reflection of the scrutiny with which I am subjecting myself as the individual who has to make this decision.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
3 hours ago, MikeTheNurse said:
Thanks, everyone, for continuing the discussion.
The topic seems to have touched a nerve, which is why I thought to bring it up here in the first place.
As a new nurse, I don't have the instinct, wisdom, or experience that some of my peers possess. Nevertheless, I am sometimes placed in the same situations as my peers and have no choice but to approach each situation from my own perspective - which is as a novice nurse who is dealing with everything for either the first time or the second time since reading about it in a book for perhaps a week some years ago in nursing school.
There are some situations where I can simply study up on a patient's diagnoses on my own time to refresh my memory or to learn about what nursing considerations are appropriate, and I do that.
But this is indeed a gray area. It is absolutely open for debate about what consent means when you have a patient who arguably does not possess the level of cognition necessary to make decisions regarding their own care.
For example, we don't "allow" people to commit suicide. But I recently had a patient whose wife died. Grieving, the patient made a decision to stop taking his antibiotics until he became septic. I sent him away to the hospital, where I later learned that he was placed on hospice and passed away a week or two later. Prior to his being sent away, psych and the care team were both aware and involved.
One of the responses referenced a law in the UK that helped to clarify what should be done in the event that a patient does not possess the cognitive ability to make decisions regarding their own care. As I practice in the United States, this legal mechanism does not apply in my situation. That said, given the unclear nature of my initial question as evidenced by the passionate and varied discussion which followed, it seems like a standard that we can all follow would be helpful so that the decision doesn't fall upon a nurse who is new to the practice and only has about 10 minutes to spend with that patient per day in an 8 hour shift to begin with. I don't mean this as a complaint, but simply that the cumulative knowledge of many experienced healthcare professionals deciding upon a standard of care that novices like myself can follow would benefit the patient more than it would benefit me.
As I work in a Rehabilitative setting, many have suggested that I involve the patient's care team. Members of the care team have been notified, but aside from experimenting with changing the resident's medications and supplements, the specific issue of medication concealment or the resident's right to refuse have not been specifically addressed. As my facility has been in a transition process, there hasn't been a hierarchy of nurses to address the issue with, either. I will continue to pursue the issue as the situation evolves and, once again, I very much appreciate everyone taking the time to share their different perspectives on the issue.
There are valid points on both sides of this argument, and by referring to it as an "ethical dilemma," I'm not trying to assign judgement upon anyone for making the decisions they thought were best in their particular cases. It's simply a reflection of the scrutiny with which I am subjecting myself as the individual who has to make this decision.
Thanks again, everyone, for your input.
I have to give my hats off to you as a new nurse for asking the questions and starting a conversation. I've been in nursing for a while and I've seen some nurses dismiss similar issues after their shift is over and it never gets addressed until it becomes a more serious problem.
Dementia pt's don't "refuse" medications because they are confused and they simply don't know what it is you are doing, or what is it you are giving them exactly.
Suggesting there is some way to make them understand, when the reality of the matter is, this isn't even remotely possible to do in the first place because of their cognitive deficit medical condition. That is to say, it's simply not possible to make them understand.
However, I still fail to understand where the so called ethical dilemma situation exists exactly. All you are trying to do is provide them with the best medical treatment and personal care possible. That's all that should really matter at the end of the day isn't it?
Even though the cognitive impaired patient may not understand what I am doing, or what medication I am giving to them exactly, I would certainly never do anything that causes any harm to them, end of story!
I suspect those who have no previous experience working with the dementia population have no way of understanding the reality of the situation.
While I do sincerely support and appreciate the sentiment of ensuring the principles of ethical nursing practice is upheld, maintained and followed, you need to understand the world of nursing isn't exactly a matter of seeing everything in simple black and white either.
I think the bigger question is whether or not providing anything other than purely palliative treatment to patients with advanced dementia is really "the best medical treatment and personal care possible". Personally, I don't think that treatment intended to sustain or prolong life is more beneficial than harmful in many if not most patients suffering from advanced dementia.
Specializes in LTC, assisted living, med-surg, psych.
I have fought more battles about medication than I can count. Mostly, they were about discontinuing the many vitamins and supplements some residents were prescribed that really served no purpose other than to make their families feel they were getting good care. They often refused meds because the sheer number of them in the medicine cup was overwhelming. It took a lot of education, and sometimes I had to work to get the family AND the doctor onboard, but I was successful about half the time and those residents were less apt to refuse meds since there weren't so many.
Granted, some supplementation is necessary when there are wounds and/or weight loss, but for a lot of dementia patients it just doesn't make sense to throw a bunch of vitamins and minerals at them and have them refused (or thrown right back at you!). Just my $.02 worth.
Specializes in Psych, Addictions, SOL (Student of Life).
On 9/20/2019 at 5:13 PM, Jory said:
Medications are no different than if a resident stops eating because of advanced dementia. It is the natural course of the disease and to me, there is virtually zero quality of life when they get that bad.
If they refuse, they refuse. If not taking meds leads to their death, that is the natural order of life.
This!
Having watched three beloved relatives go down the rabbit hole of dementia I have made it clear that if I were to get Alzheimer's or some other form of dementia I want all life supporting measures to be stopped and only comfort measures. This includes insulin for my diabetes any blood pressure or cholesterol meds etc... There is nothing ethical or merciful in flogging a failing body thus extending one's suffering. I had a similar case in a LTC where a patients was clearly suffering but the POA/husband also had dementia and actually believed his wife would get well and walk out of that nursing home. The Physician called for a hospice consult and brought in the sons and daughters and basically said he refused to continue treating her unless she was placed on Hospice which was the kindest thing to do.
This is such a fine line. I've dealt with situations like this before. A parent of one of my psych patients actually asked me to give her child a placebo and tell him he was getting medication. I did not comply and she understood.
Does your facility have a bioethics department? If so, they can get involved in addition to docs and psych.
I never worked w/Parkinson's patients, but my understanding is that muscle relaxants (is she on baclofen?) not only relieve discomfort from dystonia, but delay or prevent contractures, which are difficult, if not impossible to treat once they occur. Assuming she's on neurontin for pain? If she doesn't get that, she's probably going to be less mobile, miss or not participate in therapy and thus begins an ugly cycle. I'm sure I'm not telling you anything you don't already know and I really don't like medical professionals who seem to know what's best for everyone. I'm thinking if you ask her what are her reasons for not wanting to take all of the meds, you might be able to come to a compromise, as others have posted above.
Finally, you say she's not completely oriented, but is she actively hallucinating or delusional? If so, that adds a whole new wrinkle to the conversation...
I have fought more battles about medication than I can count. Mostly, they were about discontinuing the many vitamins and supplements some residents were prescribed that really served no purpose other than to make their families feel they were getting good care. They often refused meds because the sheer number of them in the medicine cup was overwhelming. It took a lot of education, and sometimes I had to work to get the family AND the doctor onboard, but I was successful about half the time and those residents were less apt to refuse meds since there weren't so many.
Granted, some supplementation is necessary when there are wounds and/or weight loss, but for a lot of dementia patients it just doesn't make sense to throw a bunch of vitamins and minerals at them and have them refused (or thrown right back at you!). Just my $.02 worth.
I absolutely agree with reducing polypharmacy especially where vitamins/supplements are concerned. I can't tell you how many LTC residents I have that take a few prescription meds that are probably beneficial along with a boat load of vitamins that probably aren't.
Case in point is one of my residents that takes a blood pressure med and a diuretric which are beneficial, a statin that is in my opinion of questionable benefit along with a list of vitamins and supplements including Vit B6, Vit B12, Vit C, Vit D, Vit E, multivitamin with minerals, Preservision vitamin, calcium, tums [which also is calcium], biotin, magnesium, zinc, fish oil, aspirin, tylenol and an OTC omeprazole. Many of those OTC meds are probably useless to her plus a few of them are multiple pill doses and a few like the calcium, fish oil and Preservision are just huge pills and as she has declined she is having a harder time swallowing all these. She recently changed primary providers so I am hoping we can get a lot of these eliminated soon though I am not sure the family will be agreeable. Her previous doctor did try to reduce some of these and it was a hard no from the POA, maybe this new MD will have better luck.
Specializes in LTC, assisted living, med-surg, psych.
Don't you just love families? Sigh...The good ones are worth their weight in gold, but when I was working in LTC we seemed to have more of the helicopter type. I was tempted more than once to tell them that if they thought our care was insufficient, they should take the resident home and care for him or her themselves. But of course, I smiled and carried out their requests to the best of my ability like a "good little nurse" who never complained...at least, not until I got to the break room and unloaded to whoever was in there eating their lunch!
Crash_Cart
446 Posts
Dementia pt's don't "refuse" medications because they are confused and they simply don't know what it is you are doing, or what is it you are giving them exactly.
Suggesting there is some way to make them understand, when the reality of the matter is, this isn't even remotely possible to do in the first place because of their cognitive deficit medical condition. That is to say, it's simply not possible to make them understand.
However, I still fail to understand where the so called ethical dilemma situation exists exactly. All you are trying to do is provide them with the best medical treatment and personal care possible. That's all that should really matter at the end of the day isn't it?
Even though the cognitive impaired patient may not understand what I am doing, or what medication I am giving to them exactly, I would certainly never do anything that causes any harm to them, end of story!
I suspect those who have no previous experience working with the dementia population have no way of understanding the reality of the situation.
While I do sincerely support and appreciate the sentiment of ensuring the principles of ethical nursing practice is upheld, maintained and followed, you need to understand the world of nursing isn't exactly a matter of seeing everything in simple black and white either.