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?
Specializes in Psych, ER, Resp/Med, LTC, Education.
definately a difference when you have a terminal patient--I did medical before psych and had that happen and yeah it is different--more like you talk about, with social work. But in a patient that is not there is a mood disorder most likely and the passive SI needs to be addressed. I don't believe a patient can refuse the psych consult. They may fight it but hopefully the psychiatrist will be skilled enough to be able to at least get the patient to listen......they are usually pretty good at what they do I have found. I am in psych ER so out docs get called to all over the hospital sometimes and it usually is the docs request not the patients necessarily.
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.
the licsw may even approach the pt about hospice services...
I find these situations incredibly complex to think about. I haven't read enough information to make much of a judgement about the original post except to say that I agree that the staff should not be putting meds down the tube that the pt has refused to take po. To do so without a formal psych finding of legal incompetence is battery and is a criminal offense. Don't do it until the consult is in the chart and all the legal i's are dotted and t's are crossed. Even then, I'd have the facility's attorney and/or risk manager on board, as well as the ethics committee.
When I worked on an AIDS unit I researched this area a bit, since in the 90's many people with AIDS considered suicide an acceptable option. In the legal advice section of one medical journal, I read of a case in which a man suffered a completely severed cervical spinal cord in an accident. He was taken to an ER, refused admission or any treatment and had people willing to take him home and care for him. The hospital had to let him go ... the opinion was that the pt was fully aware that he was unlikely to survive without intervention and refused tx anyway ... he simply didn't want to live as a quadriplegic and had the right to allow himself to die.
This was not passive suicide ... this was a competent adult deciding that the quality of the life possible for him was not acceptable.
It was pointed out in the article that the refusal of food, fluids or medical tx is not, by itself, evidence of suicidality. I agree, however, that the pt in the OP needs to be seen by psych in order to tease out what's going on emotionally.
I have seen more than one patient take this route when faced with spending the rest of his/her life in a facility.
Specializes in Psych, ER, Resp/Med, LTC, Education.
Okay I think we have established that this woman is not a terminally ill patient, correct? How old is this woman/patient we are talking about here? Any other medical problems? ...or was she just in the hospital primarily for the purpose of the G-Tube? ....was she suffering from anorexia? Exactly what meds was the doc wanting so badly for her to get--that she was refusing?
Hi, thank you everyone for your replies. This is obviously a complicated subject and I appreciate everyone's input. No, this woman is not terminal at this point. She 's in her sixtys, originally came in for a CABG, ended up with an AICD, became anemic, has been transfused numerous times, developed CHF, has gone into flash pulmonary numerous times requiring intubation and days on the vent. She is has basically been bouncing back and forth between my floor (an icu step down) and the icu. She's on dobutrex for the CHF, BNP is through the roof.. I could go on and on, she's developed renal failure, the list goes on. So she's very sick, and she knows this. I agree a psych consult needs to be make, she is obviously severely depressed. After all the intubations, she made herself a do not intubate, and has recently made herself a med code only... I think she's ready to go, but scared to say so...
I am in canada ...but there has to be some kind of we call it the pink slip which is part of the mental health act that deems a person not competant to make their own medical decisions. This has to be signed by 2 doctors. Then the doctor has the RIGHT to make this decision, otherwise it is the persons choice. This sounds like depression to me and the depression needs to be dealt with...if the person isn't willing to take medication then some psycotherapy might be a good idea.
I agree, a situational depression is a definite possibility, especially since the pt is sending mixed messages about what she wants: accepting the ng tube and feedings, yet refusing meds.
Psych support is definitely called for, if she'll accept it.
And I agree with Leslie that a hospice or palliative care person might be able to help the pt clarify for herself what she wants.
But, personally, I don't view being sick of being sick as diagnostic of mental illness or legal incompetence. Sounds like she's had one nasty time of it with one complication after another. I hope she gets the support she needs to figure out for herself what she wants and that her choice is respected.
But, personally, I don't view being sick of being sick as diagnostic of mental illness or legal incompetence. Sounds like she's had one nasty time of it with one complication after another. I hope she gets the support she needs to figure out for herself what she wants and that her choice is respected.
i'm not sure anyone is really questioning her competence to make decisions.
rather, it is a cya intervention for when a psych eval would inevitably be ordered.
i would love to see how this woman responded to antidepressants.
she really is giving mixed messages here, and to me, sounds like a cry for help.
If the patient you described hasn't been diagnosed with anorexia/bulemia then there are enough similarities to motivate you to read some care plans about that and suggest the things in them that seem appropriate for her, be adopted.
Definitely get a psych consult and give as much support to this person as possible, as the thin line between life and death is being walked here. Just sitting there and encouraging her to tell you anything about herself that she wants to share, could help get a handle on the cause of her behavior. I know that may seem time consuming - time you don't have, but you can present her with the meds she refuses, and when she does that, put it down and ask if at any other time someone wanted her to take something she didn't want to have (it doesn't have to be a medication). The response could bowl you over, but for all that's holy, don't reflect any judgment about what she says! Just chart it, and be sure her doctor sees it.
Sometimes we focus on getting a task done, when it isn't the thing that necessarily will accomplish the real objective. Getting into a power struggle with the ordering physician(s) won't get her better, either.
i'm not sure anyone is really questioning her competence to make decisions.
rather, it is a cya intervention for when a psych eval would inevitably be ordered.
i would love to see how this woman responded to antidepressants.
she really is giving mixed messages here, and to me, sounds like a cry for help.
leslie
She's already on antidepressants, well, until she started refusing to take most of her medications. Before taking them, not only was she down and depressed, she was just downright mean and inpatient. Now she's just down, not mean.
RochesterRN-BSN, BSN, RN
399 Posts
definately a difference when you have a terminal patient--I did medical before psych and had that happen and yeah it is different--more like you talk about, with social work. But in a patient that is not there is a mood disorder most likely and the passive SI needs to be addressed. I don't believe a patient can refuse the psych consult. They may fight it but hopefully the psychiatrist will be skilled enough to be able to at least get the patient to listen......they are usually pretty good at what they do I have found. I am in psych ER so out docs get called to all over the hospital sometimes and it usually is the docs request not the patients necessarily.