Ethical issue regarding antipsychotic

[ksusn]

Hello,

I am a student nurse and I was pulled to work in the ED the other night to be a sitter for a psych pt. The pt has had a history of being very aggressive and claims to have seizures (which were determined to be fake by RN and MD). The pt was very agitated/anxious at the time with security on stand by. The nurse had drawn up olanzapine (antipsychotic) to give IM. The pt asked for antiseizure med and insisted the RN tell him the name of the drug and the drug class in which he was about to receive. The RN told him the correct name of the drug, but told him it was an anti-seizure medication. I understand that if the pt had been violent, he may not have had a choice in whether he recieved the drug or not. However, I feel like it was wrong for the nurse to lie about the medication. Any thoughts on this or how the situation should have been handled? Thanks!

[MunoRN, RN]

What you're describing is unfortunately not all that unusual, but you are correct that it's not appropriate to lie to a patient about what medications you are giving them.

There are specific criteria and processes that must be met to take away a patient's right to be informed of and consent to the medications they are given, and it's possible that these requirements were met and that you weren't aware of that. Although even when a patient is found incompetent I still am honest with them about what I'm giving, just with the added clarification that they can't refuse it.

And while the patient had not yet been physically violent, escalating agitation is sufficient to establish a risk to others, you don't have to wait until they've already had a violent event.

[blondy2061h, MSN, RN]

If his seizures are pseudoseizures it is antiseizure in his case.

[YumCookies, BSN, RN]

Honestly I don't blame the RN - I would say anything to my psych patient to get the psych med they need for both their safety as well as my own. xD

Instead I might've said something like "this medication will help relieve your symptoms" or "it'll make you feel more comfortable". That way you are technically not lying...

[Scottishtape]

blondy2061h said:

If his seizures are pseudoseizures it is antiseizure in his case.

This.

Edit: I was also thinking maybe it was an off label use, but I'm not finding anything credible, so I removed that portion of my post ?

[elkpark]

Why the double post?? In either case, definitely wrong and not something I would ever have done.

[Lisacar130]

If he is a person prone to having pseudoseizures, I could justify loosely connecting zyprexa to preventing these episodes.

"Psychogenic seizures or events are caused by subconscious thoughts, emotions or "stress," not abnormal electrical activity in the brain. Doctors consider most of them psychological in nature, but not purposely produced. Usually the person is not aware that the spells are not "epileptic."

Zyprexa can help calm a patient like this down and therefore this could prevent a pseudoseizure. I might have explained it a differently with different wording but I could see the nurse wanting to have the patient be cooperative during the IM administration. His "seizures" are involuntary but are caused by stress, thoughts and emotions. Any med that reduces antipsychotic symptoms surely can help with this. I might say it "helps with the type of 'seizures' you're having."

[Here.I.Stand, BSN, RN]

Pseudoseizures are not "fake" -- they are psychogenic vs. neuro-electric. This is frequently misunderstood; in fact in my first job on a neuro floor, I saw an RN draw up NS and administer it, saying aloud "We'll give him some Ativan," as if the pt could hear her. I made the cardinal mistake of sticking a Yankauer in his mouth, as he had started to vomit. He bit down so hard it left DEEP tooth marks -- in hindsight I can't believe he didn't break any teeth.

We actually had many pts admitted for 24-hr EEG monitoring, and were determined to be having pseudoseizures. Literally the ONLY distinguishing feature was that EEG.

I would be more comfortable however, as a previous poster suggested, saying "the goal of thus med is to help prevent seizure-type episodes," vs lying about the pharmacological class.

[Guest219794]

ksusn said:

Hello,

I am a student nurse and I was pulled to work in the ED the other night to be a sitter for a psych pt. The pt has had a history of being very aggressive and claims to have seizures (which were determined to be fake by RN and MD). The pt was very agitated/anxious at the time with security on stand by. The nurse had drawn up olanzapine (antipsychotic) to give IM. The pt asked for anti-seizure med and insisted the RN tell him the name of the drug and the drug class in which he was about to receive. The RN told him the correct name of the drug, but told him it was an anti-seizure medication. I understand that if the pt had been violent, he may not have had a choice in whether he received the drug or not. However, I feel like it was wrong for the nurse to lie about the medication. Any thoughts on this or how the situation should have been handled? Thanks!

The pt has had a history of being very aggressive.

The pt was very agitated/anxious.

I feel like it was wrong for the nurse to lie about the medication.

The RN told him the correct name of the drug, but told him it was an anti-seizure medication.

A- "This is Olanzapine, it is an anti-seizure medication."

B- "This is Olanzapine, it will help stop your seizures."

Which did the nurse say? Either one helps the patient get the medication he needs to keep him safe. B is also 100% accurate, and meets any definition of "ethical". But, in the heat of the moment, would you really draw an ethical line between these two statements? Is the nurse who was heads up enough to porifice his/her words in a potentially dangerous situation really any more ethical than the nurse who is just trying to keep the patient safe?

Lets look at option ?

"This is Olanzapine. It is not an anti seizure medication, it is an antipsychotic. Oddly enough, it actually lowers seizure threshold. But, you my friend, are not having seizures. You are having a psychotic episode."

This is the most truthful answer, and the most likely to cause harm to the patient. Would an ethical nurse choose this?

• Beneficence - to do good.
• Non-maleficence - to do no harm.
• Respect for Autonomy.
• Fairness.
• Truthfulness.
• Justice.

Sometimes these principles can conflict with one another.

Even if, in your situation, the nurse chose statement A above, he or she was still maintaining the first 2 principles, despite a sub-optimal choice of semantics.

It looks like you are focused on Deontology. "This theory judges the morality of an action based on the action's adherence to rules."

But, there are other ways to look at this.

Ethical Relativism- "The theory states that before decisions are made, the context of the decision must be examined."

Utilitarianism- " The value of the act is determined by its usefulness, with the main emphasis on the outcome or consequences. "

Feminist Theory- "Feminist theory requires examination of context of the situation in order to come to a moral conclusion."

Once, while working in the ICU at 0300, I got a call from a nurse on the floor, asking me to come upstairs and pretend to be a doctor. (I am a middle aged man) She said that she had a little old lady with dementia who really needed to take a medication. The nurse had told the patient "The doctor really thinks you should take this medication". The patient said she wanted to hear that straight from the doctor.

I went up stairs, walked into the room, and said "Mrs Smith, you need to take this medication".

Regardless of the fact that I did not lie, I deliberately mislead the patient. Did I do the wrong thing?

I recently had a patient with pseudoseizures as a result of conversion disorder. The doctor was able to stop these seizures by pushing 3 ml of normal saline. This allowed us to accurately diagnose and treat the patient. On a moral scale of 1-10, where do we stand on this?

Those are my thoughts on this. Now, I am going to ask you the question you asked:

What do you think would have been the right thing to do with this agitated anxious patient with a history of aggression?

[Lisacar130]

That was the best answer I've ever seen in my life

[blondy2061h, MSN, RN]

This somewhat reminds me of a situation I had years ago. I wasn't the patients nurse, but was working that night. The patient was refusing lasix because he didn't want to be up peeing all night. He now had a foley, but was increasingly confused and couldn't understand that he wouldn't need to be up peeing all night. He was experiencing pulmonary edema. He was full of crackles and becoming more and more anxious, tachypnic, and short of breath. His nurse even tried to sneak him the lasix through his IV line once he was sleeping. He woke up.

I went in and told him I had a medication for him. "What is it? Not lasix, right?" he barked.

"It's furosemide," I replied.

"What's it for?"

"Shortness of breath."

He took it and improved. And he wasn't up all night peeing.

[JKL33]

Wanted to post this article, I think a portion of it may be quoted above.

I have witnessed physicians sit down at the bedside and try to have compassionate discussions - they use the term "attack" or "the difficulties you're having today" as opposed to "seizure." Lo and behold, that's a suggestion in the article, too. I think it makes sense given the general confusion (especially for patient and family) surrounding this issue - this situation breaks my heart when people don't have any real comprehension that the origin of their attack/seizure may be different than an epileptic seizure. I wonder how they're supposed to get proper help for the long term.

So, that's the example I've seen and it's what I now do too. I tell the patient that the doctor has ordered a medication called _______ that s/he feels is going to help with the type of attack/difficulties you've been having today. If they ask what class of medication, I tell them. If violent behavior is a concern I wait until the team is prepared to administer the medication before making my statement. I would never say that this is the ony proper way that things must be done in these inherently unique situations - - but I do try to stick to it whenever it is even remotely reasonable to do so.