I work on an acute adult inpatient unit. We have an extremely aggressive patient who is involuntarily committed. He is child like and becomes aggressive when he is told no or doesn't get his way. Otherwise, he is actually pretty likable. He has a behavioral plan in place that says to offer his meds PRN meds PO twice when he is in need, and if he refuses force an IM. this is after trying other options to de-escalate. I understand and agree with this, but the other night staff disagreed while he was being held down and waiting for the nurse to draw up his meds...
His meds were taking a while to be prepared, about 5-7 minutes, which seemed like a while since he was in a physical restraint. The hospital supervisor and security were able to verbally de-escalate him during the time. He was no longer being restrained and had calmed down. He said he would take the meds PO. He began crying and saying "I'm sorry". The director of nursing and the treatment team were the ones who impressed upon staff that the behavioral plan must be followed by everyone. This incident occurred on a weekend and they were not present to clarify the plan at the time.
The charge nurse said "no, it's too late. He's getting the IMs". The charge nurse was in the nursing office during all of this and the supervisor was with the patient. The supervisor disagreed and gave them PO without incident. We had no problems with him after that. Her rational was "...he is agreeable. Not only would it be unethical, but it risks him escalating and disturbing the mileu again".
This caused staff to turn on each other, and everyone was interpreting the behavioral plan differently. We have not heard anything from the DON or treatment team regarding this. Both sides of the argument emailed their perception of the incident to the DON.
My question is:
If a patient becomes agreeable to take PRN meds PO, after originally refusing, can they be forced with an IM? Is that ethical and following least restrictive/invasive treatment?
It all depends on the situation and patient. Having worked crisis, I have dealt with so many patients who are either manipulative or labile to the point that once they've acted out, giving a PO is "too little too late". Example, a patient who acts out, hits staff, throws something...whatever. One instance of this occurred recently whereby they patient had been acting out all night. The doc refused to order anything until it was out of control IMO. They had to be escorted to seclusion with the door open for a "time out". The order was finally given for PO Zyprexa. I knew this patient would refuse, and they did. After a period of calm, the patient began to act out again. This time staff was "hit", albeit minor hitting. I called and informed the doctor that the patient was refusing POs and hitting staff. Finally got the order for IM. Naturally, upon entering the room with the syringes, the patient attempted to bargain and ask for PO. I personally was against it and so was everyone else. We gave the IMs. Patients always try to talk their way out of things once they see the needle. Manics are good at that. I've also had antisocials try and manipulate into taking POs just to cheek them and continue with their behavior.
It all depends on the situation and patient. Having worked crisis, I have dealt with so many patients who are either manipulative or labile to the point that once they've acted out, giving a PO is "too little too late". Example, a patient who acts out, hits staff, throws something...whatever. One instance of this occurred recently whereby they patient had been acting out all night. The doc refused to order anything until it was out of control IMO. They had to be escorted to seclusion with the door open for a "time out". The order was finally given for PO Zyprexa. I knew this patient would refuse, and they did. After a period of calm, the patient began to act out again. This time staff was "hit", albeit minor hitting. I called and informed the doctor that the patient was refusing POs and hitting staff. Finally got the order for IM. Naturally, upon entering the room with the syringes, the patient attempted to bargain and ask for PO. I personally was against it and so was everyone else. We gave the IMs. Patients always try to talk their way out of things once they see the needle. Manics are good at that. I've also had antisocials try and manipulate into taking POs just to cheek them and continue with their behavior.
I have to agree. If they agreed to take the meds PO but when the time came refused and started acting out again--especially if they became violent in any way--then giving the med IM is justified, even if they agree again to take it PO. The patient had their chance but reneged on their word--now it's becoming a safety issue.
Good for you!! I sometimes think too many people take things too far, and its such a slippery slope! I want to try to maintain my integrity and not act of desperation or emotion....it can be a challenge and not always popular.
Where i work it really depends on the unit. On the inpatient floors most cases we would go ahead and give the Po unless we have a reason to suspect it is a ploy on the patients part. In the crisis unit once we go hands on 9 times out of 10 the patient is put on a bed and in 4 points so we would give the im as releasing one of the 4 points or even 2 so they can sit up is a huge safety risk to us.
TCASII, ADN
198 Posts
It all depends on the situation and patient. Having worked crisis, I have dealt with so many patients who are either manipulative or labile to the point that once they've acted out, giving a PO is "too little too late". Example, a patient who acts out, hits staff, throws something...whatever. One instance of this occurred recently whereby they patient had been acting out all night. The doc refused to order anything until it was out of control IMO. They had to be escorted to seclusion with the door open for a "time out". The order was finally given for PO Zyprexa. I knew this patient would refuse, and they did. After a period of calm, the patient began to act out again. This time staff was "hit", albeit minor hitting. I called and informed the doctor that the patient was refusing POs and hitting staff. Finally got the order for IM. Naturally, upon entering the room with the syringes, the patient attempted to bargain and ask for PO. I personally was against it and so was everyone else. We gave the IMs. Patients always try to talk their way out of things once they see the needle. Manics are good at that. I've also had antisocials try and manipulate into taking POs just to cheek them and continue with their behavior.
Sometimes you have to force meds.