I have noticed that I don't share the same view on Physician ordered fluid restrictions as most of the nurses I work with. I agree with educating the patient about why they need to limit their fluid intake as well as addressing issues that might be causing a patient's desire for water such as a dry mouth or chronic cough. I also agree that we shouldn't offer water beyond the fluid restriction when a patient isn't asking for water. I disagree with the idea that a patient who is capable of making their own medical decisions can be denied water even if they have exceeded their fluid restriction when they ask for water.
Some nurses draw the line at getting water for patients, saying that if the patient wants to get their own water then that is out of their control, leaving only ambulatory patients with the ability to obtain water. Other nurses take it even further, putting bed alarms on patients so they can yell at them when they get up to get water.
I agree it is frustrating to be treating a patient for fluid overload when they drink more fluids than they should, and care contracts are often appropriate (if we admit you to the hospital then you have to abide by your fluid restriction or you'll be discharged) but even prisoners of war can't be denied water, this strikes me as potential abuse.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
Yes the patient has the right to refuse treatment. The AMA forms will back us up in case they absolutely refuse. Sometimes it is way convenient for us to just say sign it and in our minds we say 'good luck with that' or 'let's see how well you can do without following treatment' *evil laugh*
What are we there for if not to give them the best treatment? NPO might seem to trivial especially for the lay person. If they get up and get a drink themselves, it's out of our control, esp when it's from a toilet eyw. But no way should we help them out and give them that drink. Again it's a case to case basis.
Who defines what's best for the patient, us or the patient? I agree, it's frustrating when a patient refuses a heart cath for an MI since it is the best treatment, but rather than punishing them for what we view as poor decision making, we should support them in their own individual wishes and goals, regardless of whether or not we would make the same choice. That's what we do.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
If they get up and get a drink themselves, it's out of our control, esp when it's from a toilet eyw. But no way should we help them out and give them that drink. Again it's a case to case basis.
If the priority is purely what's best for the patient, then wouldn't we want to still maintain portion control and the ability to track accurate I&O's?
I think as a general rule, finding your patient drinking out of the toilet is a sign that you may need to re-evaluate your plan of care.
Specializes in Cardiac Telemetry, Emergency, SAFE.
Whose plan of care is it? It should be thePatient's plan of care, not the Physician's or anyone else's...
So shall we let the patient write their own prescriptions then too? I know that Id personally have a floor of Pts getting 4mg "fast push" dilaudid every 2 hours.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
So shall we let the patient write their own prescriptions then too? I know that Id personally have a floor of Pts getting 4mg "fast push" dilaudid every 2 hours.
I think we can all agree that patients shouldn't be writing their own prescriptions, but they should be able to refuse treatment and decide what prescribed medications they don't want to take.
I think we can all agree that patients shouldn't be writing their own prescriptions, but they should be able to refuse treatment and decide what prescribed medications they don't want to take.
Here I have to respectfully disagree. The patient does not have the education and experience to be a part of the decision making. Sure they can choose to comply or not, but there has to be an educated and expert opionion guiding the overall plan. Sometimes ignorance is bliss and sometimes it's fatal.
To me the very fact that the patient has come to the hospital gives the implicit consent that the patient has come to us for treatment. By coming to us they are giving us permission to develop a treatment plan relying on the knowledge that we as healthcare practitioners are experts in their particular ailment.
I'm all for patient choice, and if my patient refuses medication then I educate them on why we picked that medication. If the patient refuses I chart the refusal and contact their physician. I stil go back to my original point that their automony ends with me enabling them. If they are ambulatory (a rarity in the ICU I grant you) then they make their own choice and they have to live with the results, however if they are non-ambulatory I will not provide them with water past their restriction. Call me what you want, I will not do it.
Here I have to respectfully disagree. The patient does not have the education and experience to be a part of the decision making. Sure they can choose to comply or not, but there has to be an educated and expert opionion guiding the overall plan. Sometimes ignorance is bliss and sometimes it's fatal.
To me the very fact that the patient has come to the hospital gives the implicit consent that the patient has come to us for treatment. By coming to us they are giving us permission to develop a treatment plan relying on the knowledge that we as healthcare practitioners are experts in their particular ailment.
I'm all for patient choice, and if my patient refuses medication then I educate them on why we picked that medication. If the patient refuses I chart the refusal and contact their physician. I stil go back to my original point that their automony ends with me enabling them. If they are ambulatory (a rarity in the ICU I grant you) then they make their own choice and they have to live with the results, however if they are non-ambulatory I will not provide them with water past their restriction. Call me what you want, I will not do it.
And thats the part that the people who consider a fluid restriction enforcement a violation of rights don't get. Ask any case manager............sitting in the hospital driving up costs and refusing treatments is not an option. I've seen many a pt. D/C'd after refusing a CT or tx that is necessary not only for their well being but for justification of being in the hospital. Refuse too many things......and its just not possible to convince insurances to pay for anything at all.
If you don't want to comply with a fluid restriction, then your option is to leave AMA. Staying in the hospital driving up costs for yourself and the hospital isn't.
If you are unable to walk and leave AMA, let your wishes be known for a transfer to another facility that will treat you without the restriction.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
The logic with eriks' argument has to do with the actions of "a reasonable and prudent nurse". If you are ever in a legal situation this is the standard that you will be judged by. If you gave the coumadin to the patient with the INR of 6.0 and they developed a head bleed and stroked and died or suffered permanent disability you would be liable. It's not simply a matter of giving a pill simply because it is ordered, but having the knowledge of the disease process and how the medication will interact with it in addition to potential effects of the medication. The "reasonable and prudent nurse" would hold the dose and contact the physician for further orders.
I view a fluid restriciton in the same light. I'm not sure what area you work in, but in my area I have taken care of patients with horrible CHF. On lasix drips and dopamine/dobutamine and still fluid overloaded. Sometimes diurectics are not enough and if the patient has a very low EF then letting them exceed the fluid restriction can be very harmful. I realize that the patient has autonomy, however part of my state's nurse practice act says that I plan and participate in the plan of care as ordered by the provider. To me this means that I follow the orders (as appropriate) and I will not willingly circumvent the plan of care.
Allowing the patient to violate their fluid restriction by willingly bringing them water, to me is not a legally defensible position. I feel it is also wrong to willingly help a patient harm themselves, they may not know how their actions can harm them but I've seen the end result too many times.
Well said! And KUDOS to you for knowing and learning your state nurse practice act.......practicing outside the act will get one in DEEP trouble!
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
That's my concern, it doesn't sound like we believe the patient has the choice to comply or not and that we believe A&O patients can be forced into compliance, often without the ability to leave the hospital or fend for themselves in the hospital.
Oh! They can choose.......They can choose not to comply but I can choose not to participate. You cannot FORCE an alert and oriented patient to comply but you don't have to participate. You document,document,document and explain to the patient that although you cannot stop them you cannot and will not help them. I explain what I will do ie:chips/swabs and what I won't do ie:cups, and tell them to take it up with the MD on rounds. That is when the subject of the patient not participating in their care and honest conversations need to occur and include family. If they still don't want to comply then the discussion of AMA should occur. If they persist one of three things usually happen. The patient gets mad and leaves AMA, the family decides to make the patient comply, or the doc gives in and adjusts the order. In the case of hyponatremia due to water intoxication if there is a psych component, fluid restriction can be enforced wether the patient complies or not.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
Oh! They can choose.......They can choose not to comply but I can choose not to participate. You cannot FORCE an alert and oriented patient to comply but you don't have to participate. You document,document,document and explain to the patient that although you cannot stop them you cannot and will not help them. I explain what I will do ie:chips/swabs and what I won't do ie:cups, and tell them to take it up with the MD on rounds. That is when the subject of the patient not participating in their care and honest conversations need to occur and include family. If they still don't want to comply then the discussion of AMA should occur. If they persist one of three things usually happen. The patient gets mad and leaves AMA, the family decides to make the patient comply, or the doc gives in and adjusts the order. In the case of hyponatremia due to water intoxication if there is a psych component, fluid restriction can be enforced wether the patient complies or not.
This seems to come down to an issue of our action vs inaction. It's easier when a patient refuses a pill because it involves inaction rather than action on our part, which makes us feel less complicit in what we view as the patient's poor decision making. So what if you have a patient who was admitted for A-fib and has a heparin drip going. The patient then refuses the heparin drip even though it is already running and therapeutic. Turning it off would require us to do something that could harm the patient, is this a situation where we can choose "not to participate"?
And yes, if there is a psych component involved, then a fluid restriction can be enforced, but only after the patient has been found unfit to make their own medical decisions by either a physician or Licensed Mental Health Professional.
HamsterRN, ADN, RN
255 Posts
Who defines what's best for the patient, us or the patient? I agree, it's frustrating when a patient refuses a heart cath for an MI since it is the best treatment, but rather than punishing them for what we view as poor decision making, we should support them in their own individual wishes and goals, regardless of whether or not we would make the same choice. That's what we do.