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.

[Rose_Queen, BSN, MSN, RN]

On 9/11/2019 at 12:13 PM, MikeTheNurse said:

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?

Recovery wasn't an issue here, but when my mother was dying from metastatic cancer, you bet we made sure she got her medications! Without the morphine, she was in pain. Without the haldol, she was ripping off her clothes and shrieking. Now, she was mentally incapacitated due to the hepatic encephalitis; as her family/Dad as POA, we had the choice to make. We made what we know is the right choice and slipped those meds in water if she was drinking or told her we were going to wet her mouth if she wouldn't- her dry mouth was uncomfortable enough that she'd willingly open up. What it comes down to is benefit vs. risk and the mental capacity of the patient.

[morte, LPN, LVN]

On 10/28/2019 at 1:26 PM, kbrn2002 said:

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.

Get rid of the large ones for safety reasons, get rid of the statin and omeprazole. B12 comes in a sublingual. Have you tried her without the BP med? Two sources of Ca++? Or is the Tums for indigestion? What is the B6 for, ie was the patient ever treated for TB? Whatever is left, can the family get a compounding pharmacy to put into say three tabs , 1 tab tid...

[kbrn2002, ADN, RN]

9 hours ago, morte said:

Get rid of the large ones for safety reasons, get rid of the statin and omeprazole. B12 comes in a sublingual. Have you tried her without the BP med? Two sources of Ca++? Or is the Tums for indigestion? What is the B6 for, ie was the patient ever treated for TB? Whatever is left, can the family get a compounding pharmacy to put into say three tabs , 1 tab tid...

Believe me I'd love to get rid of good number of these. Problem is not the resident so much as the family/POA who has resisted all efforts thus far to reduce some of these. Heck it wasn't too long ago the POA wanted to add another supplement based on something she read on Dr Google and thankfully this new primary MD refused. That's the only reason I have some hope this MD might possibly be able to remove at least a few if the POA can be convinced. We've started crushing her meds to make the swallowing a bit easier but as you could imagine she's not too fond of this!

[MunoRN, RN]

5 hours ago, kbrn2002 said:

Believe me I'd love to get rid of good number of these. Problem is not the resident so much as the family/POA who has resisted all efforts thus far to reduce some of these. Heck it wasn't too long ago the POA wanted to add another supplement based on something she read on Dr Google and thankfully this new primary MD refused. That's the only reason I have some hope this MD might possibly be able to remove at least a few if the POA can be convinced. We've started crushing her meds to make the swallowing a bit easier but as you could imagine she's not too fond of this!

I get that it's easier for Physicians to just give in to families on these issues, but the POA doesn't actually have agree to allow medications to be removed from the patient's regimen, it's up to the Physician to determine what medications are appropriate to offer.