Ethical issue regarding antipsychotic

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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!

Specializes in ED, psych.

Great post, hherrn.

My patients, especially in the heat of the moment when they're about to receive an IM, do not enjoy hearing the word "antipsychotic." Who would? I know I don't like it, and I take one nightly for bipolar disorder. It tends to set one off even more so ("I'm not psychotic!").

So when a patient asks, I generally tell them WHY they are receiving it, like others have mentioned:

"This will help with racing thoughts..."

"This will help your anxiety ..."

And yes ...

"This will help with the seizure activity you've been experiencing ..."

... Because it does.

Usually this is enough, as the patient (in many cases) is seeking relief from those symptoms.

But I don't lie either. If the patient is insistent on drug class, I will tell them. This is also why I don't give an IM injection for agitation by myself and have others waiting in the wings; this patient may not be happy hearing "antipsychotic."

If a patient is on the verge of aggression and is close to throwing a punch at me or throw a chair, I'm not about to break out Lexicomp and tell them all they need to know about the med they are about to take. But I will inform them in the safest way possible for all involved.

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I'm curious if the patient had court ordered meds here...

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Specializes in Short Term/Skilled.
Davey Do said:
A lot of Patients don't want to hear they've been prescribed an antipsychotic such as olanzapine: "I'm not psychotic!" they say, whether they are or aren't.

So I say, "This med is prescribed for racing thoughts and to help with other mental processes". They're more accepting of that.

Maybe it's just me and the fact that I work in LTC but I can't really think of any scenario where saying "anti-psychotic" would be helpful. Yes, we know that's what it is, but sometimes classifications like that are better left to be used among medical staff, etc.

I feel like "This pill helps with your mood changes/sadness/anxiety" is perfectly fine.

Do people really approach patients and discuss their "anti-psychotic" meds?

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Specializes in LTC, assisted living, med-surg, psych.
pixierose said:

My patients, especially in the heat of the moment when they're about to receive an IM, do not enjoy hearing the word "antipsychotic." Who would? I know I don't like it, and I take one nightly for bipolar disorder. It tends to set one off even more so ("I'm not psychotic!").

I freaked out the first time I was put on an AP. I said the same thing ("but I'm not psychotic, I'm just a little manic") and I was very reluctant to start the prescription. Now I'm on two of them, and I can't imagine what my life would be like without them and my other psych meds. I still don't like the word "antipsychotic", and doubtless wouldn't be very happy about it in the context of it being given to me because my behavior is out of control. But these drugs are very valuable and I wouldn't hesitate to offer an explanation to a patient as to what he or she is taking and why. I've never been comfortable outright lying to patients. However, I have said things like "this medicine is to help you relax and sleep" or "this will help you think more clearly". It all depends on the situation and the patient.

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Glycerine82 said:
Maybe it's just me and the fact that I work in LTC but I can't really think of any scenario where saying "anti-psychotic" would be helpful. Yes, we know that's what it is, but sometimes classifications like that are better left to be used among medical staff, etc.

I feel like "This pill helps with your mood changes/sadness/anxiety" is perfectly fine.

Do people really approach patients and discuss their "anti-psychotic" meds?

The patient in the OP's scenario demanded to know the class of medication. There are plenty of patients who are savvy enough to do such, for good and not-so-good reasons. That's what we're discussing - a situation where a patient suspects that you are not preparing to give pain meds or run-of-the-mill and more-familiar anxiety meds, and so they press the issue.

You can explain the medication's therapeutic effects thoroughly, but there are some who will demand to know the class. Then your choice is to 1) Tell the truth (won't go well, many times) 2) Refuse to answer (expect them to refuse to take it) 3) Lie (not ideal).

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Specializes in Maternal - Child Health.

If anyone here would like a good perspective on the categorization of psychiatric meds and the attached stigma, I highly recommend reading "A Spectrum Approach to Mood Disorders" by James Phelps, MD.

He also maintains a website with much of the same information. I wish I had been introduced to these concepts years ago.

PsychEducation | Treating the Mood Spectrum

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Specializes in ED, psych.
Glycerine82 said:
Maybe it's just me and the fact that I work in LTC but I can't really think of any scenario where saying "anti-psychotic" would be helpful. Yes, we know that's what it is, but sometimes classifications like that are better left to be used among medical staff, etc.

I feel like "This pill helps with your mood changes/sadness/anxiety" is perfectly fine.

Do people really approach patients and discuss their "anti-psychotic" meds?

Yes, during my daily med passes I tell patients what med(s) they are taking. There are quite a few who do ask, "what is (insert med)?" And several will ask the class as well. I'm honest.

As someone who takes an antipsychotic herself (but I would never tell my patients or coworkers), I like to normalize the language used. I hate it myself, but it's because I stigmatize myself (if that makes sense). It wasn't until my 3rd psychiatrist who said, "hey, it's a med and you need it... ignore the label ..." I try to do the same with my patients. Yeah, it's an antipsychotic. It sounds scary and horrible ... but it's merely a label.

But in the heat of the moment? I try to stay away from language that may increase agitation. "Antipsychotic" is one such term. I won't lie, but I'll use other descriptors that address their behavior (decrease anxiety, for example) before racing to terms that may incite aggression, self injurious behavior, etc.

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This was outside of clinical, it was at the hospital I work at. Security and RN's were nearby, I was just more so there to record what the pt does q15min and alert staff if I see him become aggressive when no one is in the room.

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Specializes in Critical care.
Glycerine82 said:
"Your sleeping pill is in here" and so your trazodone

"this is a pain pill" also known as tylenol

"your mom isn't here right now" because she died in 1972

I mean, you gotta do what you gotta do. I'm not going to lie if I can help it, but I will phrase my words very carefully whenever I need to, that's what I would want if I were my patients.

I use the brand name of IV acetaminophen with some patients instead of telling them it's IV Tylenol. I want them to give it a chance to work instead of automatically assuming it won't work. If it doesn't work then we'll try something else. I also don't lie if they ask if it's Tylenol.

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You can make a connection to his agitation and psychosis to excited delirium. That covers Olanzapine as a medication that can prevent seizures.

This isn't an ethical grey area at all. The pt psychologically needed the medication. The RN did not lie or even misrepresent the medication. The order might have been for a different indication, but as far as that particular patient goes, he got what he needed.

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Given that Hherrn already gave the definitive answer to the OP I would like to add, It is very easy to sit on the sidelines and judge another persons actions. With no person consequences or responsibility for the outcome and all the time in the world to think of the best possible answer we can all be confident that we would have said and done exactly the right thing. Try and understand that nursing isn't always easy or routine and most of us aren't perfect every time in the heat of the moment. Instead of judging this nurse use it as a learning opportunity to refine what you will do differently in your future nursing practice.

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Quote
I use the brand name of IV acetaminophen with some patients instead of telling them it's IV Tylenol. I want them to give it a chance to work instead of automatically assuming it won't work. If it doesn't work then we'll try something else. I also don't lie if they ask if it's Tylenol.

How timely.

I just made that decision a few days ago.

I had a PT get 3.6 MG dilaudid in 2 hrs with no relief. Another nurse suggested IV Tylenol, for which I got an order. I have given it in the past, and had decent results. The PT expressed some skepticism, but I gave it a good sell job having read the research on the drug, and my experience with it.

Complete resolution of pain. Then all that dilaudid caught up, but that's a different story.

I realized that by calling it Tylenol, I was giving correct information, but misleading the patient. I had developed some rapport and trust, nonetheless, what the PT heard was "I am giving you a drug you know to be ineffective against the type of pain you have."

Despite my success in that instance, I am done giving IV Tylenol. In fact, I don't think I will be giving any IV acetaminophen. I will be giving Ofirmev. It's a drug not frequently used here, but has been proven to treat the kind of pain you are having.

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