Ethical question

[achelle06]

I work at a long term care facility, and one of our younger residents is suspected of "cheeking" her meds. The dr wrote an order to crush meds and give with applesauce. My question is does she have the right to refuse for them to be crushed?

[KelRN215, BSN, RN]

Thank you all for your replies. The patient is competent to make decisions. I understand that she can refuse her medication, but the order states to crush all meds. Patients can refuse any aspect of their care so in my opinion, it seems like she could still refuse that. Am I wrong in my thinking?

If someone brought me a bunch of crushed meds and said "here, take this", I would refuse.

[jadelpn, LPN, EMT-B]

If the patient is competent, then in fact she can refuse to take the medication. There are many other court advocated avenues to "make" someone take their medications (if mentally ill).

In Massachusetts here's the link

What is a Rogers Guardianship? | Massachusetts Guardianship Association (MGA)

Where all signs indicate that she is cheeking them, then there could be some behavioral issue as to why she is cheeking them (control, a plan to use them, sell them, a manifestation of her diagnosis...). By crushing said meds, then that would give the patient the opportunity to refuse them, as to cheeking and hoarding, or cheeking and throwing them away, whatever it is that she is doing with them.

With all this being said, I am assuming the patient is mentally ill. If you are talking that the patient is cheeking her BP meds or some other medication that doesn't affect mental status, again, there's a behavioral component to that as well. Sometimes it is that they want a condition change to "go to the hospital". Sometimes it is a matter of someone not liking how the meds make them feel.

If the patient is developmentally delayed, then I would go back to square one with this patient. Does the patient realize that she needs to swallow the medication? I know, sounds weird, but cognitivelly delayed people sometimes "forget" that is what they are to do. And start sucking on a pill like a breath mint, tastes awful, and spits it out--but doesn't want to "offend" you by spitting it out in front of you. Equally, there are many adults who can not swallow pills. And for some embarrasing to admit.

If you were to explain what it is you are doing ie: it is time for your medications. You need to swallow the pills, I can give them to you one at a time if you would like. Would it be easier for you to swallow with pudding? I am not sure that the pill I gave you you were able to swallow lets look. I need to crush this medication, as it is important for you to take. Would you like applesauce or pudding?

Until you know what it is that she is doing with the cheeked medication, I would be mindful--as the last thing anyone wants is for her to take a boatload if in fact this is her plan. And I would inventory all of her items with another nurse just to be sure that there's not 50 haldol in a bag in her closet.....

[achelle06]

As I said, I know that she can refuse to take the medication. My question is can she refuse them to be crushed, but still receive the medication? She is not mentally ill and is competent. She is suspected to be cheeking the narcotic pills because of past drug abuse. One nurse claims she seen her cheeking her pain medication, but the patient denies this. I have been giving her the medication whole and marking "refused" on the mar beside of the order "Crush meds and give with applesauce." I just want to know if that's ok. She has no problem swallowing, and is alert and oriented.

[NurseDirtyBird]

Ok, so you have documented the refusals of crushed meds on the MAR. Now, you call the MD and tell them the patient is refusing to comply. The patient can refuse any aspect of care, including taking crushed meds. But if the order states something like, "Percocet 5/325 one to two crushed tablets q4 PRN," then it's crushed or nothing. Follow the order, document refusals and report to the MD.

If the order is separate and reads (as many do in SNF) "Medications may be crushed," then you have discretion. The patient can refuse, but you must also follow the order as written.

I think it would be wise to contact the MD for clarification either way.

[LadyFree28, BSN, LPN, RN]

Ok so you have documented the refusals of crushed meds on the MAR. Now, you call the MD and tell them the patient is refusing to comply. The patient can refuse any aspect of care, including taking crushed meds. But if the order states something like, "Percocet 5/325 one to two crushed tablets q4 PRN," then it's crushed or nothing. Follow the order, document refusals and report to the MD. If the order is separate and reads (as many do in SNF) "Medications may be crushed," then you have discretion. The patient can refuse, but you must also follow the order as written. I think it would be wise to contact the MD for clarification either way.[/quote']

This.

We really can't answer this question, because it will be up to you to collaborate with the physician on the resident refusing meds crushed when the resident has a KNOWN, documented pocketing of her meds; the dilemma is if you are giving them whole (because she refused them crushed) and is found later that she has a stash or even worse, she took her stash all at once and is found unresponsive in the worst case scenario.

You must collaborate with the physician and the healthcare team, including your resident on a way to best have medication compliance for HER benefit, if possible.

I would not give her meds whole when there is an order and known history of pocketing meds . If she is refusing to take meds crushed, there is always liquid form as well...or IM; usually with the plan of IM meds, usually that stops the pocketing of meds, at least in my experience...

[jadelpn, LPN, EMT-B]

And just be careful of the crushing, as oxycontin (if this is a pain med she uses) can NOT be crushed (or chewed, which is another whole issue). And if the patient has chronic pain, I would argue the term "addict"--however, just really clarify.