Force a pt to turn or not? (Slighty long)

[kazmomRN]

Hi all,

I am new here and I have a question for you all.

I took care of a vent dependent pt with end stage muscular dystropy who was in with pneumonia. He is trached, but can whisper to make his needs known, and is alert and orientated. He is also the type of pt that needs micropositioning (turn my neck, pull my legs down, ect). He also has 24hour caregivers at home and becomes very needy in the hospital.

Like with most MD pts he is very bony. He for the most part has intact skin with really no pressure issues except his coccyx is red, and looking like it could break open at any time. Wound and ostomy was consulted yesterday and suggested a different bed (Flexicare eclipse), tegaderm or allevyn to the site, or even a protective barrier wipe to the area to help create a barrier. He refused all suggestions. When I did my first assessment this am, the skin was still intact. I then spent the next hour repositioning, oral suctioning, and suctioning his trach once. He then actually slept for the next hour or so.

Then for the rest of my shift I did his multiple requests for microrepositioning as I call it. I attempted to look at his coccyx again multiple times in the shift, but he always put me off saying that he was comfortable. I would suggest turning him over more and propping with a pillow, but he never would let me. He for the most part directed how he wanted to be positioned. Now when I did my charting I made sure in my eval notes to document on how repositioning was directed by the pt, and my suggestions/requests were turned down.

Now towards the end of the shift my Assistant Director came to tell my how his ex-wife/caregiver had called into administration to complain about the evening shift(the prior day) on how they never answered his lights (rang as this time, no came in until this time), repositioned him, and other multiple complains. I let her know about the issues with his refusal of W&O suggestions for his coxxyx and how I was not able to relook at it after the beginning of my shift, and that I documented about his directing me how to position him. Her comment was that I should have made him turn, as that is the standard of care in our unit. My point back to her was he is fully alert, and aware of the concerns about his skin issues, and I made attempts to turn, but he flat out refused.

My thoughts are that he has the right to refuse care, as he is orientated and I did let him know the risks to his skin, but he is an adult and can make his own decisions.

Sorry for the length, but please let me know your thoughts.

[WSU_Ally_RN, BSN, RN]

From what I have learned, any patient that is alert and orientated, and aware of risks, can refuse any medication, treatment, or comfort measure they want. You are never allowed to FORCE a patient to do something against their wishes, as this could be considered assult/battery by the patient and family.

[Super_RN, BSN, RN]

Someone alert and oriented is able to make their own decisions. Albeit we may not agree with their choices, document, document, document, which it seems you did a great job of doing :) You cannot force a patient to do anything (and of course I sometimes wonder why they refuse all treatment, yet don't want to be discharged). I am glad you stood your ground. In my opinion it is NOT ok to force someone to do anything and the fact that you were told to do so is even worse.:angryfire :angryfire

[elkpark]

Yes, a patient who is A&O and legally competent to make decisions for her/himself has a right to refuse to be turned, the same as s/he has the right to refuse any other type of treatment. To turn this man against his will would legally be assault. However, you are correct (protecting yourself and the facility) to document clearly that you have repeatedly explained to him the risks of his not turning and that he verbalizes that he understands those risks and accepts them (ideally, he would be able to repeat back to you what the risks are, and you would document that).

However, the "mixed messages" from him and his ex-wife are going to create problems for the unit staff. Does your facility have a psychiatric consultation-liaison service, psych social worker, or some way to get someone in there who can talk with the patient, the ex-wife, and staff about how the facility can best meet his needs (and what is reasonable/possible for staff to do)? I have been involved in cases similar to this (as a psych CNS on a psych consultation-liaison team) where we actually drew up a "contract" on paper specifying what the patient was willing to do to participate in her/his care/recovery and what the staff could and could not do.

As a last resort, if the patient is not willing to particpate in treatment, the facility always has the option of discharging him. The patient has a right to refuse treatment that is recommended/offered by the hospital staff, but the hospital is not obligated to keep him if he does so ... (I've been involved in situations like that, also.)

[LoriAlabamaRN]

Yes, the patient has the right to refuse any treatment, including turning. But as stated above, this must be documented thoroughly. I had a resident who refused to turn and refused to turn- then tried to sue us because she developed a bedsore that became infected. Fortunately, I had documented each night that she refused to allow the CNAs to turn her, and that I had explained the importance of it to no avail. Because of that charting, we were able to prove that we were not negligent.

[BBFRN, BSN, PhD]

I would document, document, document...and then try to get him an air bed if he doesn't already have one.

[labman]

Wow the trend goes on. I agree with the above posters. If he is alert and oreanted. If you touch him against his wishes would be battery. Remember to document document document... If he wasn't turned and you didn't write he refused then it looks like you just didn't do it.

[Bipley]

Nothing to add, everyone else is absolutely correct. Just remember, in a situation like this you really can't document too much. Document your little heart out.