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.
I agree that we can refuse to get the patient a cheeseburger or cigarettes, but there are baseline rights for a dependent adult, at least in my state, that include access to food and water.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
Unless the physician writes otherwise..............status-quo.
So a competent patient will continue to receive a treatment that they do not consent to without the ability to leave? What if the patient says fine, make me comfort care? Do we have the option not to be an accomplice to their poor decision making then?
So a competent patient will continue to receive a treatment that they do not consent to without the ability to leave? What if the patient says fine, make me comfort care? Do we have the option not to be an accomplice to their poor decision making then?
Now you're grasping for straws. The issue at hand is a pt. not complying with fluid restrictins. Leave it at that. There are millions of unmentioned variables that can be brought into play to make on side right or wrong. But, in the end, the fact still remains.........if you knowingly give someone on fluid restrictions water and there is a poor outcome with said pt.................no one is going to back you up in court. Especially not the pt. rights activists and detached admin. who insisted you do.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
Now you're grasping for straws. The issue at hand is a pt. not complying with fluid restrictins. Leave it at that. There are millions of unmentioned variables that can be brought into play to make on side right or wrong. But, in the end, the fact still remains.........if you knowingly give someone on fluid restrictions water and there is a poor outcome with said pt.................no one is going to back you up in court. Especially not the pt. rights activists and detached admin. who insisted you do.
My example all along has been a competent patient who is unable to obtain there own water where other attempts to alleviate their thirst have failed. What I am trying to determine is what variables would have to exist for a dependent patient to receive water, ie would they need to agree to comfort care?
If, legally, a nurse can't participate in a patient's poor decision making, if you knowingly stop a heparin drip on a competent patient who refuses the treatment do you consider the nurse liable, and if so does this perceived liability override the patients ability to refuse a treatment? I realize this example is not the original example, but I'm curious how universal this rationale is, or if it just applies to fluid restrictions, and if so, why is it only limited to fluid restrictions?
So if you knowingly stop a heparin drip on a competent patient who refuses the treatment do you consider the nurse liable, and if so does this perceived liability override the patients ability to refuse a treatment?
hopefully the pt would refuse a heparin gtt before tx began.
but, if s/he changed his/her mind, i'd turn off gtt, notify md, and document thoroughly.
and so, no, it wouldn't override pt's ability to refuse.
if a pt opts not to comply with npo status, i'd notify md and get further orders, i.e., order for x amt of fluids per shift, remain npo by staff, lift order completely, etc.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
hopefully the pt would refuse a heparin gtt before tx began.
but, if s/he changed his/her mind, i'd turn off gtt, notify md, and document thoroughly.
and so, no, it wouldn't override pt's ability to refuse.
if a pt opts not to comply with npo status, i'd notify md and get further orders, i.e., order for x amt of fluids per shift, remain npo by staff, lift order completely, etc.
and then i'd carry it out.
iow, it's not my/nurse's decision to make.
leslie
That's my question, whose is the decision maker, and if it is the patient's decision then why would we help a patient not comply with one treatment but continue to enforce another?
I think the big thing here is that, unlike with prisoners of war, you aren't depriving the pt of water to punish them. It isn't a form of torture - you're trying to help the patient - that is the concept of beneficence - if you can't do good, at least do no harm. Plus, it isn't as though you are depriving them of hydration of any kind or forever.
My example all along has been a competent patient who is unable to obtain there own water where other attempts to alleviate their thirst have failed. What I am trying to determine is what variables would have to exist for a dependent patient to receive water, ie would they need to agree to comfort care?
If, legally, a nurse can't participate in a patient's poor decision making, if you knowingly stop a heparin drip on a competent patient who refuses the treatment do you consider the nurse liable, and if so does this perceived liability override the patients ability to refuse a treatment? I realize this example is not the original example, but I'm curious how universal this rationale is, or if it just applies to fluid restrictions, and if so, why is it only limited to fluid restrictions?
The problem though is that being thirsty won't kill you, but letting a fluid overloaded patient get more overloaded will. I fail to see why you are continuing to drive this issue, there seems to be an impass. It seems you are squarely in the "let the patient have their way" field while others are in the "protect the patient from themselves" field. I guess we will have to agree to disagree.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Not performing interventions that a competent patient refuses is not practicing outside any state's practice act.
Agreed......but a nurse should not participate in their non compliance and give them water, just as you cannot force them to comply. Nurses can refuse to give a glass of water and explain to the alert patient why they cannot paticipate in his non compliance just as one cannot restrain the patient because they lap water out of the toilet. All needs to be documented and a call to the MD needs to be made, that's all. Obviously, it is easier to help a patient comply in a critical care setting that up on the floor.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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. AGREED!
Ice chips are made of water.
This is such an age old difficult dilemma. Each response is individual to the situation. The problem.....if you are giving the heparin and the patient doesn't want it you are forcing the patient against their will. Turning it off when one knows full well the consequences and there is a bad outcome like the patient strokes........who's liable.
I am not sure 100% several things come into play. The heparin being dc'd you'd get an MD order to discontinue. If you aren't comfortable shutting it off let someone in charge know and let someone else shut it off change assignments. I have been uncomfortable with other drugs and have the MD give them instead. (after a good butt chewing by the MD) BUt if it is wrong or excessive it remains wrong and you are liable because you gave it! But if the doc refuses to give a dc order and tell you to restrain apatient that is alert to keep them from pulling out their IV you are liable, they cannot be restrained. But if you stop it because the patient refuses, don't have and order and something happends you are liable.
I guess we are just trapped no matter what we do, classic Catch 22. In general.....Never give a drug you aren't comfortable giving. Would another "resonable and prudent nurse" make the same decision? If you give water when there is no order to, technically you are going against an MD orderand practicing medicne without a liscence. To tie them down to keep them from obtaining water is unlawful restraint. Good judgement and common sense need to prevail. This dilemma will go on for all eternity........damned it we do damned if we don't.
Remember two heads are better than one and five is even better...........ask for advise! (and carry malpractice insurance:))
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
The problem though is that being thirsty won't kill you, but letting a fluid overloaded patient get more overloaded will. I fail to see why you are continuing to drive this issue, there seems to be an impass. It seems you are squarely in the "let the patient have their way" field while others are in the "protect the patient from themselves" field. I guess we will have to agree to disagree.
Pain usually won't kill you either, yet we give pain medications anyway even though giving narcotics is probably the most dangerous thing we do as nurses. From an ethical standpoint, we seem to accept trading some risk for in order to provide patient comfort in some instances and not others, and I'm curious as to how we make that decision.
I find this topic interesting, if there were clear and universally agreed upon answers, I would have lost interest long ago.
HamsterRN, ADN, RN
255 Posts
I agree that we can refuse to get the patient a cheeseburger or cigarettes, but there are baseline rights for a dependent adult, at least in my state, that include access to food and water.