Ethics

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I have a hypothetical situation that I need input from other nurses. Let's say that there is an individual that has dementia, schizophrenia and has a legal guardian. This individual resides in an adult care home. the prescriber prescribes an LAI with the guardian's approval. The prescriber ask you as the nurse to give the injection monthly, but you have to lie to the patient and inform them that the shot is a "corticosteroids or another medication". When the patient ask if they can see the lab results that justifies the need for the shot, you are ordered to say I don't have it, but it is an ordered medication. Patient is not having any active psychosis, not in crisis. As the nurse being ordered to give the injection, are you going to lie to your patient?

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Specializes in Critical Care.

Has the patient been declared incompetent to make their own medical decisions?

Regardless of how the guardian was appointed, the patient still retains the right to be aware of the treatments they are receiving, even if they may not be legally allowed to refuse those treatments. Not even a judge can "order" you to lie to the patient about why a treatment is being administered.

The legal requirement of the POA or court appointed guardian is to ensure the choices a patient would make if they were competent to do so are being followed so long as those choices don't violate any laws, so if there is sufficient reason to believe the patient would competently refuse a medication then it is the legal responsibility of the nurse to refuse to administer it, regardless of what the guardian or POA says.

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3 minutes ago, MunoRN said:

Has the patient been declared incompetent to make their own medical decisions?

Regardless of how the guardian was appointed, the patient still retains the right to be aware of the treatments they are receiving, even if they may not be legally allowed to refuse those treatments. Not even a judge can "order" you to lie to the patient about why a treatment is being administered.

The legal requirement of the POA or court appointed guardian is to ensure the choices a patient would make if they were competent to do so are being followed so long as those choices don't violate any laws, so if there is sufficient reason to believe the patient would competently refuse a medication then it is the legal responsibility of the nurse to refuse to administer it, regardless of what the guardian or POA says.

the legal guardian has the authority to make medical decisions for the patient. But, the patient still has the right to know what medication or treatment they are receiving right? even patients who are in psychiatric institutions have the right to know what meds they are taking. will you provide the correct information to the patient if you were the nurse? even with the guardian's and prescribers approval?

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Specializes in Critical Care.
9 minutes ago, chingay said:

the legal guardian has the authority to make medical decisions for the patient. But, the patient still has the right to know what medication or treatment they are receiving right? even patients who are in psychiatric institutions have the right to know what meds they are taking. will you provide the correct information to the patient if you were the nurse? even with the guardian's and prescribers approval?

The legal guardian has the authority to make the medical decisions which to the best of their knowledge are the decisions the patient would make if they were competent to make medical decisions.

If there was a court order to defy a patient's stated wishes such as in the case of involuntary psychiatric admissions, then I'm still legally required, in every state, to inform the patient of what I am doing and why.

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3 minutes ago, MunoRN said:

The legal guardian has the authority to make the medical decisions which to the best of their knowledge are the decisions the patient would make if they were competent to make medical decisions.

If there was a court order to defy a patient's stated wishes such as in the case of involuntary psychiatric admissions, then I'm still legally required, in every state, to inform the patient of what I am doing and why.

thank you for your input ?

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Just throwing out a whole different angle: we have cases like this in peds all of the time, but it's very common that we aren't allowed to tell the kids what treatments they're receiving. I'm not just talking about babies; we'll have school-aged kids and teenagers who aren't allowed to know about their care. I've seen kids who weren't told they were going for heart transplants, VADs or planned ECMO deployment until they woke up from surgery, and I've known of kids who were getting chemo who were never told they had cancer. The hardest part is that they almost always know what's wrong (or at least know that something is wrong), but they feel as though they aren't allowed to talk about it. It is strongly against my moral code, but the hospital feels that the parent's judgment is best, and if they judge it's best to withhold information from the kids then that's what we do.

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Specializes in Psychiatry, Community, Nurse Manager, hospice.
On 6/20/2019 at 10:22 PM, chingay said:

i have a hypothetical situation that I need input from other nurses. Let's say that there is an individual that has dementia, schizophrenia and has a legal guardian. This individual resides in an adult care home. the prescriber prescribes an LAI with the guardian's approval. The prescriber ask you as the nurse to give the injection monthly, but you have to lie to the patient and inform them that the shot is a "corticosteroids or another medication". when the patient ask if they can see the lab results that justifies the need for the shot, you are ordered to say i dont have it, but it is an ordered medication. patient is not having any active psychosis, not in crisis. as the nurse being ordered to give the injection, are you going to lie to your patient?

I'm a psych nurse. I would not lie to my patient. I would tell the patient what the medication is, what it is for and the possible side effects. If the patient refuses the med after that information, I would not administer it.

Yes, a legal guardian has the right to make medical decisions. But patients with a legal guardian maintain their rights to refuse medications.

In my state, a medication override can sometimes occur for a psych patient, but NEVER with a long acting medication. Never. And the patient is always informed about the reason the medication override is happening.

What the physician is asking for is a very clear violation of nursing ethics. It may also be illegal. In my state, this is certainly illegal.

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Specializes in Psychiatry, Community, Nurse Manager, hospice.
11 hours ago, adventure_rn said:

Just throwing out a whole different angle: we have cases like this in peds all of the time, but it's very common that we aren't allowed to tell the kids what treatments they're receiving. I'm not just talking about babies; we'll have school-aged kids and teenagers who aren't allowed to know about their care. I've seen kids who weren't told they were going for heart transplants, VADs or planned ECMO deployment until they woke up from surgery, and I've known of kids who were getting chemo who were never told they had cancer. The hardest part is that they almost always know what's wrong (or at least know that something is wrong), but they feel as though they aren't allowed to talk about it. It is strongly against my moral code, but the hospital feels that the parent's judgment is best, and if they judge it's best to withhold information from the kids then that's what we do.

Why is "the hospital" making this decision? This should not be the type of thing that happens by a policy.

I am shocked that this is not decided on a case by case basis. An ethics committee should be involved.

This is going to seem harsh, but as a nurse you really are not doing your job if you are not informing your patient when you know it is to their detriment to not be informed. I am not usually this critical, but I find this unacceptable.

We have licenses because we are expected to uphold nursing values, even when policy fails.

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12 hours ago, adventure_rn said:

It is strongly against my moral code, but the hospital feels that the parent's judgment is best, and if they judge it's best to withhold information from the kids then that's what we do.

"Hospital" meaning whom? An ethics committee?

With or without psych eval and input?

Not trying to be naïve here. I'm sure there are situations where even a committee or specialist charged with making a recommendation in the patient's best interest might recommend withholding information. But in terms of 'as a general rule this is what we do' it sounds like a major violation of general medical ethics. And nursing ethics, of course.

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4 hours ago, FolksBtrippin said:

Why is "the hospital" making this decision? This should not be the type of thing that happens by a policy.

I am shocked that this is not decided on a case by case basis. An ethics committee should be involved.

This is going to seem harsh, but as a nurse you really are not doing your job if you are not informing your patient when you know it is to their detriment to not be informed. I am not usually this critical, but I find this unacceptable.

We have licenses because we are expected to uphold nursing values, even when policy fails.

I completely agree—it’s part of the reason I’m leaving Peds and going back to the NICU.

This is coming from the ICU providers, palliative care team, AND the ethics committee. I had a long conversation with an ethics committee member expressing that I thought this practice was total bull feces, but that was the final decision. I don’t know if it’s a hospital culture thing or a widespread phenemomenon, but that’s how things are done at my facility. I attended an ethics conference at another local hospital, and they have the same Peds policy. These are both two highly respected academic referral centers.

In the end, the idea is that it would be more harmful to the patient for us to tell them and have catastrophic fallout with the family than to let the family decide, especially because they have medical power of attorney. We strongly encourage the family to let us tell the kids what’s happening, but we don’t go against their wishes if they firmly believe that the child shouldn’t know.

It blows my mind, and it has caused a ton of our staff to quit.

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Specializes in Pediatrics, Pediatric Float, PICU, NICU.
7 minutes ago, adventure_rn said:

I completely agree—it’s part of the reason I’m leaving Peds and going back to the NICU.

This is coming from the ICU providers, palliative care team, AND the ethics committee. I had a long conversation with an ethics committee member expressing that I thought this practice was total bull feces, but that was the final decision. I don’t know if it’s a hospital culture thing or a widespread phenemomenon, but that’s how things are done at my facility. I attended an ethics conference at another local hospital, and they have the same Peds policy. These are both two highly respected academic referral centers.

In the end, the idea is that it would be more harmful to the patient for us to tell them and have catastrophic fallout with the family than to let the family decide, especially because they have medical power of attorney. We strongly encourage the family to let us tell the kids what’s happening, but we don’t go against their wishes if they firmly believe that the child shouldn’t know.

It blows my mind, and it has caused a ton of our staff to quit.

In my 13 years of experience, this is pretty much the standard in Pediatrics. It is really unfortunate, because when the parents want to withhold information it is always because they think it is what is best for the patient. But these kids are resilient, and smart, and no matter their age they always know something isn't right and lying to them by ommiting the truth doesn't help at all.

This has always been an ethical struggle and my biggest issue in pediatric world. I stand my ground on not participating in outright lies - so you're either going to get the truth, or I'm not going to say anything. It is still not right, but that's where I have found my peace.

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17 minutes ago, JadedCPN said:

In my 13 years of experience, this is pretty much the standard in Pediatrics. It is really unfortunate, because when the parents want to withhold information it is always because they think it is what is best for the patient. But these kids are resilient, and smart, and no matter their age they always know something isn't right and lying to them by ommiting the truth doesn't help at all.

This has always been an ethical struggle and my biggest issue in pediatric world. I stand my ground on not participating in outright lies - so you're either going to get the truth, or I'm not going to say anything. It is still not right, but that's where I have found my peace.

That’s how we get around the problem—we never ‘lie,’ but we are instructed to be super vague or redirect/distract. If kids flat out ask us questions, we’re supposed to tell them, “you need to talk to your mom/dad” (fortunately I’ve never had to do that).

One piece that’s really tricky is that giving the diagnosis is outside of the nursing scope. It’s not my place to tell a kid that they have cancer and explain what that means; if I go rogue and tell a teenager that the medication I’m giving is chemo, what are the implications if the medical team is refusing to tell them that they have cancer. It puts nursing in a really tough situation and causes a ton of nursing burnout even though the delivery of the diagnosis really isn’t in our nursing scope.

It’s terrible, because all of the literature (including Peds ethics) says its best to tell kids; it seems terribly unfair and unethical not to. But we assume that parents are the best judge of the kids’ readiness to hear that information, since in Peds parents are always right (unless they lose custody).

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