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.
Hamster, obviously you have no interest in even hearing another side to your argument. I don't even know where to start to respond to the several things you have said that I believe are misguided (or just wrong). There have been so many posts on this thread that I've wanted to quote to argue with that I gave up on that notion altogether.
The whole "denying food and water are a violation of basic human rights" concept in this example is laughable to me. Sorry. In the case of fluid restriction, you're not DENYING THEM WATER, you're denying more than x number of ml's of water. Very different. In the case of being NPO, the patient knows they are there for either a test, in which NPO is part of the prep for said test, or for something requiring bowel rest (like an obstruction), and have agreed, by being admitted, to the treatment plan. Yes, they can refuse the treatment plan, and they can do so by GOING HOME. IMO, then, and only then, can they do "whatever they like." In BOTH situations, the patient is not going to die of thirst; the NPO pt has IV fluids running if it's for an extended period of time, and the pt on a FR IS getting enough fluid to survive.
I will not provide a patient with the means to go against the best course of medical treatment. Just as I will not give a patient that is diabetic a regular Mountain Dew. If family brings it in, no I cannot stop them, all I can do is educate and document. I will not be the one that provides the means, period. When someone is on a fluid restriction, I will let them know at the beginning of my shift how much fluid I am able to provide, and will work with them to decide how much they want at what intervals. I give them as much power as I can, without going over the amount they are allowed.
Also, I do not believe this falls into the same realm of having a patient refuse medications. I'm having a hard time thinking of the wording to explain that, but in one case, it's giving, in another, it's taking away. If a patient insists on getting 3 Percocet instead of 2, I'm not going to give it anyway when my attempts at educating them on the contrary fail.
Yes, it's the "patient's plan of care," but it is so because it's ABOUT the patient, not because the patient authors it. If they knew everything to do, and could DO everything needed, they wouldn't have to be in the hospital. Most people are admitted to the hospital because they are ill, and every illness/condition has specific treatments. No patient is going to like every one of those things. If a patient opts to exceed their FR, that's on them....and on them to find the means to exceed it, if they so choose. If it's by leaving AMA, then it's by leaving AMA. Then they can drink all they want. If they don't want the treatment they need, go home.
What do you think that non-compliant patient will say in court, should their condition be exacerbated by you providing them fluid over their restriction? The patients that aren't compliant also believe that nothing about their health is their fault....what they are going to argue is that you, as their nurse, shouldn't have listened and given into their demands. They are going to make it YOUR fault. Your defense of "they told me to" isn't going to....hold water.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
Hamster, obviously you have no interest in even hearing another side to your argument. I don't even know where to start to respond to the several things you have said that I believe are misguided (or just wrong). There have been so many posts on this thread that I've wanted to quote to argue with that I gave up on that notion altogether.
The whole "denying food and water are a violation of basic human rights" concept in this example is laughable to me. Sorry. In the case of fluid restriction, you're not DENYING THEM WATER, you're denying more than x number of ml's of water. Very different. In the case of being NPO, the patient knows they are there for either a test, in which NPO is part of the prep for said test, or for something requiring bowel rest (like an obstruction), and have agreed, by being admitted, to the treatment plan. Yes, they can refuse the treatment plan, and they can do so by GOING HOME. IMO, then, and only then, can they do "whatever they like." In BOTH situations, the patient is not going to die of thirst; the NPO pt has IV fluids running if it's for an extended period of time, and the pt on a FR IS getting enough fluid to survive.
I will not provide a patient with the means to go against the best course of medical treatment. Just as I will not give a patient that is diabetic a regular Mountain Dew. If family brings it in, no I cannot stop them, all I can do is educate and document. I will not be the one that provides the means, period. When someone is on a fluid restriction, I will let them know at the beginning of my shift how much fluid I am able to provide, and will work with them to decide how much they want at what intervals. I give them as much power as I can, without going over the amount they are allowed.
Also, I do not believe this falls into the same realm of having a patient refuse medications. I'm having a hard time thinking of the wording to explain that, but in one case, it's giving, in another, it's taking away. If a patient insists on getting 3 Percocet instead of 2, I'm not going to give it anyway when my attempts at educating them on the contrary fail.
Yes, it's the "patient's plan of care," but it is so because it's ABOUT the patient, not because the patient authors it. If they knew everything to do, and could DO everything needed, they wouldn't have to be in the hospital. Most people are admitted to the hospital because they are ill, and every illness/condition has specific treatments. No patient is going to like every one of those things. If a patient opts to exceed their FR, that's on them....and on them to find the means to exceed it, if they so choose. If it's by leaving AMA, then it's by leaving AMA. Then they can drink all they want. If they don't want the treatment they need, go home.
What do you think that non-compliant patient will say in court, should their condition be exacerbated by you providing them fluid over their restriction? The patients that aren't compliant also believe that nothing about their health is their fault....what they are going to argue is that you, as their nurse, shouldn't have listened and given into their demands. They are going to make it YOUR fault. Your defense of "they told me to" isn't going to....hold water.
I think you may have missed the posts between the original and now, as everything you mention has been addressed elsewhere, I don't blame as there have been many long posts, and yes I am very interested to hear the other side of the argument and I thank you all for providing it.
From looking at laws in other states, it does appear that in some states you are correct and that in the case of a competent dependent adult, you are only required to give water, without any requirement as to amount. The wording in my state law is more specific: water must be provided "upon request", so denying water past a certain amount is specifically not allowed. Again, I'm talking about patient who is competent, unable to leave, and bedbound (a dependent adult), not someone who can leave AMA whenever they choose.
It's true that most patient refusals don't require any action on our part, but some do, like stopping a heparin drip the patient does not want.
Patients do not consent to all treatment simply by being admitted. And no, patients can't write orders but they can veto them, that is a well established legal right. No they don't have the automatic right to 3 percocets instead of 2, but they can refuse them all together. As I've stated numerous times before, patients do not have a right to soda, but they do have a legal right to water and I, as there caregiver, am legally required to provide them with it.
We can't refuse all care of a just because they refuse the "best" treatment, if they refuse all treatment then they will probably be discharged as there would be nothing left to do as an inpatient. If a patient refuses a blood transfusion would you refuse to give the epoetin ordered as the alternative or just kick them out the door?
In terms of liability, the response I got from both my risk manager and a practice officer at my state's DOH is that you really only need to notify the MD and document the refusal, if you feel it is warranted, you can have the patient sign an AMA form for the denial of a specific treatment. Yes, "they told me to" will hold water as long as the patient has not been deemed incompetent to make their own decisions, and no, poor decision making does not make a patient incompetent (this is per a Risk Manager). It's the "the doctor told me to" argument that doesn't hold water in court. The argument of "I was doing what was best for the patient" doesn't hold up either since not only is there no evidence to support any benefit to a fluid restriction, there is evidence to the contrary (more on this when I get a chance).
The next lawsuit I see for not talking to someone/treating someone like an adult.......will be the first. Now, lawsuits for harm being brought to a pt. via a nursing decision abound.
It's like they teach in school: Think things through to the end, whats the worst that can happen with a decision? Take every decision all the way through to worst case scenario.
1. Give water: Poor outcome possible, pt. dies from poor outcome not impossible. Lost license, fine, maybe jail time.
2. Don't give water: Pt. insists you "treat them like a child" and give a poor survey result. At worst, your manager gives you a scolding for not being "tactful" enough.
IDK. I wonder how many of the people who believe the ANA standards and "protecting pt. rights" will protect them from being thrown under the bus if there is a poor outcome are newer nurses who haven't experienced being thrown under the bus yet.
I know during my first year of nursing, I would have given the water and documented everything and waxed/wained about pt. rights. Fast forward through a little over four years of being on the job and my views are very different. I've had more than a few instances where managers/institutions have tried to throw me under the bus despite me following policy/procedure to the tooth.
No matter what the law/policy/procedure/standard is, it still comes down to you making the decision. If there is a poor outcome, you've done something wrong, period.
As I stated before too, yes, pt's are well within their right to do as they please............after going AMA. A pt. who is at risk for a poor outcome who wants to drink as they please, can do so at home where no one has to worry about being pinned as the bad guy for their decisions. AMA is the way to freedom if you are not interested in your health. Sitting in the hospital driving up costs are not. Ask any case manager about that one.
Ok, I guess I should have clarified the situation; the pt. was only going to get 500cc's of water before being scorted off the premises as an AMA. That was MY take on the situation, not an ongoing argument with the pt. remaining in the hospital.
You should understand something about your States Nurse Practice Act: It definitley outlines your responsibilities and rights, and your hospital policies and proceedures do the same. I am not sure where you got the idea that you are not covered for following hospital procedure and "PRUDENT ACTIONS". You are NOT liable for EVERY poor outcome, I really do not understand how you came to such a conclusion. Perhaps you newer nurses (and I can say that, I graduated in 1975)really need to bone up on your states Nursing Practice Acts. The hospital management may try to intimidate you, or "throw you under the bus"; but they cannot, if you understand your rights and responsibilities, and cite them clearly during any "meetings"
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
I should admit that I also used to enforce fluid restrictions and I don't think a hospital should be a free-for-all where patients are given the keys to the med room, free to treat themselves with the help of wikipedia. I don't believe patients can refuse safety precautions such as NPO due to aspiration risk or bed alarms, I don't even think all patients have the right to sit on the toilet without being watched (super creepy, I know). At the same time, we can all probably agree that we shouldn't be strapping patients down and performing involuntary lobotomies to treat their Gout. There is a line somewhere in there and I've been trying to figure out how we balance some reasonable humility with our tough love/ "my way or the highway" inclinations.
The unit I work on has fairly severe CHFr's; EF's of 10%, milrinone drips galore, yet no fluid restrictions, none, ever. When I float, it is usually to the medical telemetry floor which has more stable CHF patients, managed by GP's and hospitalists, whose patients are frequently on fluid restrictions. Before we stopped fluid restrictions on my floor, I enforced them like anyone else, with the firm belief that if you don't do as I say then you're killing yourself, and I don't want that on my shoulders. There was something that didn't seem right about it, but I wasn't sure what. It wasn't until the cardiologists that treat my floor announced they were no longer going to order fluid restrictions because they did more harm than good that I was able to look at it from another perspective.
Studies have shown no benefit to fluid restrictions. Not only is there not a risk of a patient getting worse without a fluid restriction, but it doesn't even delay the progress of their treatment.
This along with other studies listed at the end may not be enough to sway the most die hard fluid restriction opponent since they aren't huge and at least they don't show any harm in their use. But the negative effect they have on the effectiveness of treatment should be the deal breaker.
The Docs on my unit no longer order fluid restrictions in part because it is pointless, but mainly because they need an accurate assessment of the patient's thirst drive in order to create and re-assess the plan of care, ie do they need to titrate their ARB to reduce the patients thirst by 2 liters a day or half a liter? You can't treat something very well if you've never assessed for the presence of a problem, much less assessed the severity. The intro to this study explains the basis here fairly well:
"Thirst is a common and troublesome symptom for patients with moderate to severe heart failure. The pharmacological and non-pharmacological treatment as well as the nature of the disease itself causes increased thirst. There is no evidence in the literature about the usefulness of fluid restriction for heart failure patients. Formerly, when very little pharmacological treatment was available, fluid restriction was one of the few interventional options but nowadays when the pharmacological treatment has improved, its importance may be questioned."
(This was from 2003, the resulting study and others since then have given us more of an answer).
We now know that excessive thirst in CHF is due largely to excessive aldosterone II, which is treatable, and should be treated if you really want a successful long term treatment plan. (the article below was written in 2001 when ACE inhibitors were the preferred treatment, supposedly ARB's are now often preferred.)
As has been correctly pointed out that patients will drink as much as they want when they get home, which isn't just "their" problem, it's our problem, because it means they'll be back. And if you're concerned about the costs associated with healthcare, this is huge, with CHF re-admissions accounting for the largest single chunk of medicare spending.
All fluid restrictions do is cloud our ability to assess the patient initially as well as the ongoing effectiveness of the treatment plan, and with no benefit to balance that out with, fluid restrictions are basically poor form.
We've found that our CHF readmission rates have dropped significantly (almost 1/4 total including other interventions) since we started aggressively treating symptoms of thirst based on the knowledge of a patient's true fluid intake obtained by removing all fluid restrictions, there has not been any increase in the length of stay or complications in these patients.
What I've noticed in this thread is that it we all care about what we do, however we express it, and given the potential consequences of every little thing we do, we sort of need to operate under the assumption that everything we do undeniably correct. Just as long as we remember that the people who did routine labotomies also had no doubt they were successfully treating a wide range of conditions; 50 years from now what will people view as our version of labotomies?
I applaud our desire to do what's best for our patients, but fluid restrictions aren't it, advocating for a more enlightened and effective plan of care is.
I think you may have missed the posts between the original and now, as everything you mention has been addressed elsewhere, I don't blame as there have been many long posts, and yes I am very interested to hear the other side of the argument and I thank you all for providing it.
From looking at laws in other states, it does appear that in some states you are correct and that in the case of a competent dependent adult, you are only required to give water, without any requirement as to amount. The wording in my state law is more specific: water must be provided "upon request", so denying water past a certain amount is specifically not allowed. Again, I'm talking about patient who is competent, unable to leave, and bedbound (a dependent adult), not someone who can leave AMA whenever they choose.
It's true that most patient refusals don't require any action on our part, but some do, like stopping a heparin drip the patient does not want.
Patients do not consent to all treatment simply by being admitted. And no, patients can't write orders but they can veto them, that is a well established legal right. No they don't have the automatic right to 3 percocets instead of 2, but they can refuse them all together. As I've stated numerous times before, patients do not have a right to soda, but they do have a legal right to water and I, as there caregiver, am legally required to provide them with it.
We can't refuse all care of a just because they refuse the "best" treatment, if they refuse all treatment then they will probably be discharged as there would be nothing left to do as an inpatient. If a patient refuses a blood transfusion would you refuse to give the epoetin ordered as the alternative or just kick them out the door?
In terms of liability, the response I got from both my risk manager and a practice officer at my state's DOH is that you really only need to notify the MD and document the refusal, if you feel it is warranted, you can have the patient sign an AMA form for the denial of a specific treatment. Yes, "they told me to" will hold water as long as the patient has not been deemed incompetent to make their own decisions, and no, poor decision making does not make a patient incompetent (this is per a Risk Manager). It's the "the doctor told me to" argument that doesn't hold water in court. The argument of "I was doing what was best for the patient" doesn't hold up either since not only is there no evidence to support any benefit to a fluid restriction, there is evidence to the contrary (more on this when I get a chance).
I didn't miss any posts, I read the entire thread. I repeated points already made since you don't seem to have heard any of it, to be honest.
I never once even remotely implied that making poor decisions equated to a patient being incompetent.
I don't understand where you're pulling examples from....why would you refuse to give someone epo as ordered if someone refuses a blood transfusion, and rather "kick them out the door?" That makes no sense. If a doctor who had previously ordered a fluid restriction later d/c's it, then there is no more fluid restriction, and I give the patient what they ask for. Even if the patient's condition is the same, it's up to the doctor what is prescribed. I don't have the power to prescribe. If he says no FR, there's no FR. If he says one is needed, I will follow that order. It's not my job to change the order based on some study I've read.
Bedbound or not, ANY patient can leave any time they want to. They aren't imprisoned. They can arrange transportation, etc, all on their own, if they are competent. If they don't like the treatment prescribed, as I said, they can go, and that isn't limited to those that are ambulatory. If someone wants out, they can and will find a way.
For patients with a fluid restriction, as I said, I am not "refusing them water." If, on my shift, I can give them 200 mls, I let the patient decide how they would like that split up. If they want 50mls every 2 hours, a full 100 every 4 hours, or all 200 right away and then that's it, it's their decision. If they do not drink all of the fluids that come on a meal tray, I will give them the equivalent to that amount later on, in whatever form they choose.
I honestly have never had anyone put up that much of a fuss about it. Most patients understand the reason, and are OK with having the power over how they will get the water/fluids that it's ordered they can have.
"They told me to," IMO, WILL NOT hold up in court (again, I said "IMO." If you believe otherwise, see where it gets you). The patients willing to argue that much about getting it WILL be the ones that, in court, will say that you, the nurse, should have known better and NOT given it to them, that that's your job. If people can win millions of dollars for spilling hot coffee on their laps, they're going to win that argument, right or wrong.
If you feel backed up by your hospital's admin, go for it. If that's the case, I don't know why you're making such a big issue out of it, really.
a court is going to want to hear the nurse's thought process re decision to give fluid or not.
there is no rubberstamping one edict over the other.
if a pt is on fr r/t acute chf, you're darned tootin' i will adhere to the restrictions set forth.
same for severe lyte imbalances/h20 intoxication...anything that would knowingly exacerbate current status.
but if a pt is npo r/t forthcoming procedure and pt changes their mind (and plans to leave hosp), then of course i'd bring fluids while they're there.
it's all going to depend on why pt is on fr.
and there isn't any one statute to protect a nurse for making a bad decision.
that's the bottom line.
leslie
I completely agree with this. My responses fell in to the first example. Yes, if someone is NPO for a procedure and then decides they do not want to go through with the procedure, the NPO becomes nil and I WILL give them something to drink (after letting the doctor know that the pt changed their mind, so that if the doc would like to talk to the patient about the decision, they can before it would be delayed due to intake).
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
So if the MD D/C's the order simply based on the patient's refusal then you would give extra water? How is this not still "enabling a bad decision". If the patient's condition hasn't changed then how is no longer a bad decision on the part of the patient? In legal terms, MD orders won't protect you if you make what is truly a bad decision.
In terms of the bedbound patient who can leave anytime they want, I'll be sure to tell the next patient I have that they are just imagining the week they spend waiting in the hospital for ECF placement, they'll be relieved.
I think you misunderstood my point about the epoetin. I was referring to the assertions that a patient who refuses "they treatment they need" should just leave. A patient may refuse the "treatment they need" in the form of a blood transfusion, but that doesn't mean we deny them treatment all together.
So if the MD D/C's the order simply based on the patient's refusal then you would give extra water? How is this not still "enabling a bad decision". If the patient's condition hasn't changed then how is no longer a bad decision on the part of the patient? In legal terms, MD orders won't protect you if you make what is truly a bad decision.
In terms of the bedbound patient who can leave anytime they want, I'll be sure to tell the next patient I have that they are just imagining the week they spend waiting in the hospital for ECF placement, they'll be relieved.
I think you misunderstood my point about the epoetin. I was referring to the assertions that a patient who refuses "they treatment they need" should just leave. A patient may refuse the "treatment they need" in the form of a blood transfusion, but that doesn't mean we deny them treatment all together.
No one ever said they would, either! Where do you get that assertion?
What I know I've said the whole time is that I will follow the ORDERED FLUID RESTRICTION. D/c'ing the order doesn't make it not necessary, but it's totally different to give fluids they are ordered not to have, and to not give them because YOU THINK they shouldn't have them. That's a whole other topic, too, should it ever become a lawsuit. Going against an order and giving them fluids is obviously totally different than just deciding they shouldn't have them, if they MD says they can. It's the MD's determination whether the pt's fluid intake should be restricted, that's out of my job description and scope of practice. Following the order to restrict IS in my job description, and I will continue to follow that order (and don't even get started on the argument of holding Coumadin for a high INR, etc, because that is NOT THE SAME).
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
No one ever said they would, either! Where do you get that assertion?
What I know I've said the whole time is that I will follow the ORDERED FLUID RESTRICTION. D/c'ing the order doesn't make it not necessary, but it's totally different to give fluids they are ordered not to have, and to not give them because YOU THINK they shouldn't have them. That's a whole other topic, too, should it ever become a lawsuit. Going against an order and giving them fluids is obviously totally different than just deciding they shouldn't have them, if they MD says they can. It's the MD's determination whether the pt's fluid intake should be restricted, that's out of my job description and scope of practice. Following the order to restrict IS in my job description, and I will continue to follow that order (and don't even get started on the argument of holding Coumadin for a high INR, etc, because that is NOT THE SAME).
I got that assertion from "Yes, they can refuse the treatment plan, and they can do so by GOING HOME" and "If they don't want the treatment they need, go home". (stated by cherrybreeze)
You don't think it's part of your description to evaluate whether a treatment is appropriate before you implement it?
I got that assertion from "Yes, they can refuse the treatment plan, and they can do so by GOING HOME" and "If they don't want the treatment they need, go home". (stated by cherrybreeze)
Patients can refuse all treatments (not safety measures), a fluid restriction, just like coumadin, is a treatment.
Treatment plans change. If an MD d/c's order for blood transfusion and orders epo instead, this is the new treatment plan. If MD d/c's fluid restriction, this is the new treatment plan. There comes a point, however, that some patients refuse EVERYTHING. If the MD is made aware of the patient's desire to not be fluid restricted, and the MD believes it is necessary and does not change the order, it then falls on the patient to comply, or go home.
What you said was, "if the physician orders epo instead of a transfusion, do you not give the epo and 'kick them out instead?'" Not at all. I follow what the new plan is. No one said ANYTHING about "kicking the patient out," I, for one, said, "they can leave." Meaning THEIR OPTION, not mine.
cherrybreeze, ADN, RN
1,405 Posts
Hamster, obviously you have no interest in even hearing another side to your argument. I don't even know where to start to respond to the several things you have said that I believe are misguided (or just wrong). There have been so many posts on this thread that I've wanted to quote to argue with that I gave up on that notion altogether.
The whole "denying food and water are a violation of basic human rights" concept in this example is laughable to me. Sorry. In the case of fluid restriction, you're not DENYING THEM WATER, you're denying more than x number of ml's of water. Very different. In the case of being NPO, the patient knows they are there for either a test, in which NPO is part of the prep for said test, or for something requiring bowel rest (like an obstruction), and have agreed, by being admitted, to the treatment plan. Yes, they can refuse the treatment plan, and they can do so by GOING HOME. IMO, then, and only then, can they do "whatever they like." In BOTH situations, the patient is not going to die of thirst; the NPO pt has IV fluids running if it's for an extended period of time, and the pt on a FR IS getting enough fluid to survive.
I will not provide a patient with the means to go against the best course of medical treatment. Just as I will not give a patient that is diabetic a regular Mountain Dew. If family brings it in, no I cannot stop them, all I can do is educate and document. I will not be the one that provides the means, period. When someone is on a fluid restriction, I will let them know at the beginning of my shift how much fluid I am able to provide, and will work with them to decide how much they want at what intervals. I give them as much power as I can, without going over the amount they are allowed.
Also, I do not believe this falls into the same realm of having a patient refuse medications. I'm having a hard time thinking of the wording to explain that, but in one case, it's giving, in another, it's taking away. If a patient insists on getting 3 Percocet instead of 2, I'm not going to give it anyway when my attempts at educating them on the contrary fail.
Yes, it's the "patient's plan of care," but it is so because it's ABOUT the patient, not because the patient authors it. If they knew everything to do, and could DO everything needed, they wouldn't have to be in the hospital. Most people are admitted to the hospital because they are ill, and every illness/condition has specific treatments. No patient is going to like every one of those things. If a patient opts to exceed their FR, that's on them....and on them to find the means to exceed it, if they so choose. If it's by leaving AMA, then it's by leaving AMA. Then they can drink all they want. If they don't want the treatment they need, go home.
What do you think that non-compliant patient will say in court, should their condition be exacerbated by you providing them fluid over their restriction? The patients that aren't compliant also believe that nothing about their health is their fault....what they are going to argue is that you, as their nurse, shouldn't have listened and given into their demands. They are going to make it YOUR fault. Your defense of "they told me to" isn't going to....hold water.