ethical dilemma

[starbin]

I work in LTC. I have a senior citizen living in that LTC who is ordered NPO by his physician and receives GT feeding 24 hours a day. Everyday during meal times, he asks for food and becomes agitated because everybody else got a tray but him. He used to eat before he went to the hospital but ever since he came back from the hospital, he is NPO. He asks for food like a small baby, you should see the expression in his face- it breaks my heart. he says- I didn't eat for last one week, rescue me..give me something to eat please !!! I want a cup of water.

I asked the speech therapist for swallowing evaluation and she recommended puree diet. But the doctor did't even want to listen and it was a big NO NO from him. He just told this- "who will be responsible if he aspirates? Will you? he aspirated when he was in the hospital.". I discussed this with the speech therapist again and the speech therapist said at this time he is tolerating puree diet. She further recommended video swallowing evaluation. The MD again refused to have this test. He claimed- he aspirates and there is no need of this test. He will fail the test.

Even though we make every effort to isolate these NPO people during meal times, the smell and sight of food is not always avoidable. There are two things that aggravates the agitation in this gentleman- food and elimination. He wants to use bathroom and doesn't wet his diaper. Everytime he wants to go to the bathroom- he tries to get up and if he is not allowed he will be agitated. He will be shouting- let me go to the bathroom. It is understandable.

Day before Yesterday, he was taken to some other floor during lunch time and he became very agitated and the therapeutic recreation chief asked me to have a psychiatrist see this man and "prescribe something to calm him down". I asked- what did he want? Food or he wanted to go to the bathroom? The guy said- he didn't know, but this gentleman was out out of control. As soon as he came to the floor, he was taken to the bathroom and was very calm and quite after that.

Next day- the unit manager asked me not to feed anybody with too much of inofrmation otherwise I will be in trouble (because I told the recreation chief that food and elimination are the only two reasons for his agitation) and call the psychiatrist to increase the dosage of meds. He already is on a very high dosage of psychotropics and we know what triggers his behavior. How could we expect him to sleep 24 hours a day? Even now he sleeps most of the time. Is psychotropic a solution for this gentleman? Should I offer him food despite the physician's NPO order? how can I solve this problem?

[jill48, ASN, RN]

You are his advocate. It's sad he has no family, which makes it even harder for you because it sounds like you are his only advocate (on this matter anyway). When I read this I found it very sad, but I was also very proud of you, my sister nurse, because you have such a big heart and want the very best for your patient. You were not feeding too much information to the therapist; the therapist is part of the team; it's not like you were telling him lab results. You cannot feed him, regardless of how bad you want to, until the physician changes the order. Is there not one single family member that can speak to the doctor? Because that is probably the only thing that will make him change the order. You said that the speech therapist performed a swallow test and ordered a pureed diet? Then why isn't the doctor allowing this? I would go to the medical director and beg (yes, I would beg for my patient) to take the swallow tests into account. You probably sit back and think to yourself, "why am I pushing so hard when it's just about him wanting to eat?" Well eating is not a little thing. It may be one of the last pleasures he has left in his life. Why should this be denied to him if he can swallow pureed food? Nursing school was a long time ago for me, but I seem to remember there was some triangular diagram about basic human needs, and I'm pretty sure eating was one of them. Please don't stop fighting for him. Just be sure to do it correctly, following all orders. Good luck, sweetie. Your doing very good. :icon_hug:

[HikingNinja, BSN, MSN, DNP, RN, APRN, NP]

Be careful here. You could get into some serious trouble with your facility if they think you are overstepping your bounds. But there are ways to remedy this situation without your facility even knowing you are involved. I am guessing that this person is either Medicaid funded or private pay. If he is Medicaid funded then you should be able to anonymously contact the appropriate agency (in my state it is called the Division of Aging Services) and report this to his caseworker who must by law investigate. If it is private pay he must have someone who has power of attorney over his affairs if he has been deemed incompetent. That would be the person to contact (this person is probably listed as the emergency contact on his chart). And you can also contact licensing agency who licenses your LTC and lodge a complaint. In my state you can also do that anonymously.

Dee

[starbin, BSN, RN]

I think I will give up. I am thinking about chaging my job. I had even given a thought on calling the Department of health and senior services but decided not to. I guess the best thing for me is to quit.

[TazziRN, RN]

Quit if you dislike it and are that frustrated, but please don't leave the poor man in the lurch like that. Make the phone call. If you don't you just leave him at the mercy of other nurses who probably won't do anything. He needs another doctor with a more compassionate attitude.

[NURSE1987]

This man is lucky to have a nurse that feels so strongly about his rights, you are doing the right thing. If you decide to discuss this problem with a higher power, remind them about Maslow's hierarchy of needs.. 1.Physiological needs 2.Safety needs 3.Social needs 4.Esteem needs 5.Self-actualization needs. If this man's physiological needs (i.e. food, elimination) are not met, there is no way he can attain self-actualization ore any of the prior categories. The doctor needs to examine this situation more closely, I know it's hard for an MD in LTC w/ MANY residents. The right thing to do is at least have the tests ran, so that there can be some type of reasoning for denying the poor man's request.

[TrudyRN]

DO NOT DISOBEY DOCTOR'S ORDERS. Even if nothing happens, you are setting a bad precedent for yourself. YOU will suffer any negative consequences.

DO get everyone involved. The social worker, administrator, nursing bosses, speech therapish, et. The doc should at least get the video swallowing study.

IF HE DOES NOT RELENT: Just forget about it. I know the patient is unhappy but his problem is not worth you risking your license.

Try prayer.

[TrudyRN]

I think I will give up. I am thinking about chaging my job. I had even given a thought on calling the Department of health and senior services but decided not to. I guess the best thing for me is to quit.

It's not worth quitting. Are you going to quit evey job that has a problem come up?

Fight the good fight where you are but know when to give up and accept the doctor's orders.

[TrudyRN]

Be careful here. You could get into some serious trouble with your facility if they think you are overstepping your bounds. But there are ways to remedy this situation without your facility even knowing you are involved. I am guessing that this person is either Medicaid funded or private pay. If he is Medicaid funded then you should be able to anonymously contact the appropriate agency (in my state it is called the Division of Aging Services) and report this to his caseworker who must by law investigate. If it is private pay he must have someone who has power of attorney over his affairs if he has been deemed incompetent. That would be the person to contact (this person is probably listed as the emergency contact on his chart). And you can also contact licensing agency who licenses your LTC and lodge a complaint. In my state you can also do that anonymously.

Dee

I think it's too late for her to be anonymous. She has already been talking to the doc and the speech therapist.

[Hoozdo, ADN]

I would question this doctor carefully. If speech therapy has evaluated the pt and said he can swallow pureed food; why is the doctor so opposed to letting the pt eat? Can he be reasoned with at all?

If it came to the point where I would want to quit over it, I would question him aggresively. Is he on a power trip or what? If speech therapy said he can swallow, then he can swallow :trout: Why torture this poor patient?

[RNinSoCal]

Code status and Advance directives are the major differences in these cases. If the family and/or the patient insists on full code status then the MD has no choice but to order NPO for patients who are aspirating and my die from complications related to aspiration. Legally the MD is responsible for the pt's illnesses and/or death if a diet is ordered when aspiration is a known problem. If the family will agree to comfort care then the patient may eat and aspirate to their heart's content. I have documented on the behalf of MD and RNs alike many times when the family insists on feeding a pt with known aspiration. It is a sad and unfortunate problem that we as nurses have to witness and assist in when patients can no longer safely eat/swallow. I am sorry for all of us who witness our patients suffering from swallow difficulties at the end of life.

[withasmilelpn]

We refer some of our residents to social services, who if their poa or court appointed guardian agree, a dietary waiver is obtained that absolves the facility and physician from liability should they aspirate. It might be a way you can go. A lot of the ones who chose to go that route did well. However, I have had some patients I dreaded meal times with because they would choke and cough and gag their way thrrough the whole meal and we would stand ready to do the heimlich/ suction thing again. So, all things considered, it's a hard decision either way. Good Luck!

[starbin, BSN, RN]

It's not worth quitting. Are you going to quit evey job that has a problem come up?

Fight the good fight where you are but know when to give up and accept the doctor's orders.

I definetely will fight the good fight. I have to quit because I have no support that will help me fight. Everybody is so overwhelmed with their own stuff that they do not even want to be bothered with such things. Few people even answered me like this- What is your problem girl? If the doctor says no... why are you making big deal out of it? Forget about it.

This is not the only reason I am quitting. I just can't digest a lot of things. I will be better off somewhere else. LTC is not for me.