Ethical Question about NGs and medication administration

[BeachyRNn08]

Hi,

I'm a fairly new nurse, only 7 months experience, working on an intermediate care unit. I have a pt who is able to swallow, GI system completely functional, she stopped eating became severely malnourished. She had a NG tube placed for tube feedings. She is completely oriented, able to follow all commands and verbalize any needs. She has been on our floor for months, and has had a very complicated stay, and seems like she has given up. She refuses to get out of bed, has become incontinent, and refuses to take most of her PO medications. Again, she is able to swallow, but has the NG tube for tube feedings. When I had this pt this weekend, she was refusing to take her medications... I educated the pt about the medications, and she still refused them. Is it ethical to crush these meds and give them through her NG when she refuses to take them? I've seen nurses do this, however I didn't do so. I charted them as "pt refused" and addressed it with the MD, who just insisted we put them in her NG... The patient has obviously given up and the MDs need to address this issue, but are not doing so. Opinions please? Any similar experiences?

[lpnflorida]

I think you were correct in trying to educate the patient regarding the medications. You state she is alert and oriented times 3. I would have requested a psych consult if one is not already involved in their care. Until said consult, I would as I had time try to explore with the patient how they feel about their condition and their degree of hopelessness. I might also try and enlist the support of any close family member .

It is so difficult to keep up the morale of a patient with a long complicated medical course in any setting. This person does need an intervention of some sort , losing their trust by tricking them is not the answer however. I am sorry the doctor gave such a lame directive to a very real problem.

[Daytonite, BSN, RN]

as long as the patient's hands are not restrained, she knows and consents to what the ng tube is for. she can merely pull the tube out if she truly wants to refuse meds and food. i've had anorexics that will consent to an ng tube at first and then change their mind and pull the tube out. they justify that as long as someone else is putting the food and meds in them, they are not making the decision themselves and the burden if off of them. so, as long as the patient consents to that tube and it is in place and patent, the meds go in. when they are ready to take control they will remove the tube and decide if they want to eat or take the meds on their own.

[patrick1rn, MSN, RN, NP]

How many months has this NG tube been in her nose and into stomach ?

Why is she in your facility ? Are you a nursing home ?

Has pshyche deemed this person competent ?

Is this person able to swallow after having a tube in her for several months

I am not seeing the big picture here.

[masonRN]

The situation you're posing looks this way to me: if the patient is not only oriented, but fully understands the medication's purpose and the likely results of taking and refusing, and chooses to refuse, any person who administers against the patient's wishes is ASSAULTING them, both morally and legally (I am NOT giving a legal opinion, merely a personal opinion). The physician's belief that he/she (the MD) knows better than the patient, and can and should override the patients free choice, is a VERY dangerous opinion to have, and should be stomped out very aggressively.

Does a person have a right to live and die on their own terms? I believe they do; even if I disagree with their choices, I support their rights.

[RochesterRN-BSN, BSN, RN]

As a psych nurse I would say this patient is what we call passively suicidal. Do you not have an inpatient psych unit at your hospital? Before working psych ER I worked psych inpatient and we got patients like this now and then.....quite often they were geriatric patients but same basic idea--passive SI. Given up.

Sounds like she needs a psych consult stat and transfer to a psych unit.......they should be able to handle the tube feedings.....we did it. She needs an antidepressant it sounds like and the psychiatrists will be better able to care for this womans needs as they sound psychosomatic/passive SI.

We deal with patients refusing meds all the time and in emergency situations medical or behavioral IMs can legally be given against the patients will--for not emergant you need two docs to assess competency and the case needs to go to court for what we call "meds over objection" where a judge looks at both docs assessments and makes a decision to grant or deny the document.

Good luck......sad case, but that is my world! lol and I keep goin' back for more!@

[leslie :-D]

as long as the patient's hands are not restrained, she knows and consents to what the ng tube is for. she can merely pull the tube out if she truly wants to refuse meds and food. i've had anorexics that will consent to an ng tube at first and then change their mind and pull the tube out. they justify that as long as someone else is putting the food and meds in them, they are not making the decision themselves and the burden if off of them. so, as long as the patient consents to that tube and it is in place and patent, the meds go in. when they are ready to take control they will remove the tube and decide if they want to eat or take the meds on their own.

pt may be ok w/getting fdgs but still wants to refuse meds, for whatever reason.

it shouldn't have to come to sacrificing both food and meds.

i agree, she needs a stat psych consult to assess her competency.

and it is her right to refuse.

leslie

[Virgo_RN, BSN, RN]

The patient has the right to refuse treatment. I wouldn't give the meds.

[Michael_65]

Remember that patient autonomy trumps all. Unless the patient has been declared incompetent to make her own decisions, then it is her right to refuse any aspect of care that she wishes.

To echo a few previous posters:

1. Hold the meds and notify the attending MD. Document your actions.

2. Push for a psych consult, and also for an ethics panel.

3. Continue to educate the patient on the benefits of taking her medications.

4. Do not, under any circumstances, lie to the patient about what is going into her NG tube, or try to "sneak" medications into the tube.

5. If the MD persists in ordering you to give the meds without the patient's consent, notify your manager. Your manager may want to report this to the Director of Medicine, who will then deal with the MD.

[firstyearstudent]

I am wondering... You say the patient was alert and oriented and able to swallow pills but she is being given then through her NG tube. At my hospital, you need an order to give a medication through the NG tube. It is not just a PO order and the nurse makes the decision whether to give it PO or not. Once that issue is settled with an MD order and a route is decided on and documented (even that order "give PO unless pt. refuses, then give via NG tube), then I would ask the patient if she wants to receive the medication through her NG tube or not. She may not want to take her medications PO, yet be ambivalent enough about her own care that she will accept them NG. For instance, if she refuses to take the medications orally, I would ask, "Is it alright with you if I crush the pills up and then give them to you through your NG tube?" THEN I would make sure she gets the professional help she needs in terms of deciding how and if she wants to continue with medical interventions, most likely by getting her a social worker.

[RochesterRN-BSN, BSN, RN]

that is not really the role of a social worker........they don't deal with meds and refusal of medical care--that is what psych is for. She needs a psych consult not social work.

[beachgirl17]

I agree about needing a psych consult, but I am curious...can a person refuse a psych consult? If so, then what? Court order for the psych consult too?

[firstyearstudent]

Yeah, I guess a psych consult is in order. I guess I was just thinking about my own unit. I work on a hematology floor and many people come to a point where their conditions are terminal and they just want end-of-life care and they usually make that decision after talking with a social worker, not a psychiatrist. But I guess if you're not terminal you should talk to a psychiatrist? I don't know.

Social workers in our hospital often deal with the issues of refusal of medication or medical care, in fact they are our first line. It is usually the social worker who then speaks to the doctor and says, "I think this patient needs a psych. consult. She seems depressed and not in a condition to make these decisions."

Maybe it is just our hospital's philosophy or the fact that they are often far along in a potentially terminal illness, but we don't jump to the conclusion that someone needs a psychiatrist because they don't want treatment.