can confused pts refuse meds?

Nurses General Nursing

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I had a really confused pt today with high blood sugars. He wasn't violent, but was incredibly aggressive, and I was worried he would become combative. To what point do you force these pts to take meds (iv, subq)? I had a resident insist that there's no way a confused or can refuse meds. It's my job to give it no matter what. Do i get several nurses to force him down, potentially making his behavior worse? And if I already feel that this pt might become violent with me, do I have to wait for him to actually hit me? I'm more annoyed that she said, well he hasn't become violent yet. I think you all get the issue I'm trying to figure out. At what point is it "okay" to place yourself in harm's way to ensure a confused pt takes their meds?

Also, I just want to note, they really didn't want to add anything iv/im to help calm him. I asked.

Specializes in LTC.

You can't force a patient to take meds or partake in any treatment if they refuse, unless there is a court order.

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Specializes in Surgical, quality,management.

Prioritise what you are giving.....depending on the patient and situation. E.g. D4 #NOF BNO dam sure he is getting laxitives as that will help with the confusion.....however there are ways and means.

Hepatic encephalopathy there is no option to refuse lactulose we have used rectal tubes and NGs if no varacies to get it in.

However a LOL who is suspicious of why her tablets are a different colour than what she gets at home I would call family and get her brands brought in to reassure her.

Please don't forget to give me my PPI I have severe oesphagitis currently and if I couldn't communicate what I need retrosternal chest pain is not going to help the issue

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Specializes in Behavioral Health, Disability Case Mgmt.

You can plead, dance, beg, and go to all extremes in the book to encourage a patient to take their prescribed/ordered meds, HOWEVER, the ultimate decision is with the patient. They have the right to refuse. UNLESS, there is an ETO (emergency treatment order ) or they have been legally made incompetent and their HCS (health care surrogate) has given approval, it is patient choice. Even with HCS approval, unless the patient cooperates, PO administration falls in the hands of the patient. It may be necessary for the attending to adjust the "route" ( IE: IM, IV, . . . ). When permitted, morning coffee tastes better with scheduled meds . Just saying.

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Legally, they can refuse ...but I sometimes place ethics above legality. Once upon time, I had a patient with a brain injury who was having an allergic reaction to something. The patient was scratching himself like crazy, breaking his own skin, and unable to sleep. He was offered PRN meds, but refused because he believed that he was dead, I was dead, the doctor was dead, and medication didn't exist. He loved pudding though, so ...

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Specializes in Psychiatry, Community, Nurse Manager, hospice.

In inpatient psych RNs sometimes give patients PRN meds against their will but it has to be for safety reasons.

We do not give scheduled meds against a patient's will without a "med override". To get a med override, an ethics team is consulted consisting of people who are not already caring for the patient. The team has a doctor, nurse, social worker and other disciplines who evaluate the patient individually to determine whether or not an override is warranted.

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Specializes in Hematology-oncology.

If they are confused, and their legal next of kin or guardian consents for them, you can sometimes sneak oral meds in by crushing them and putting them in pudding, 15 mls or so of their favorite drink, oatmeal, etc. Injections are a bit tougher. I don't feel comfortable giving advice because each situation is different, and much would depend on how crucial the medication is to the overall goals of their care.

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Specializes in NICU.

Just because a patient is confused, doesn't mean they don't have rights. You can explain the benefits of the medication and the reasoning behind it but at the end of the day they can still refuse - unless it's an emergency or life/death situation of course. The only time I forced meds upon a patient that I can recall was a middle aged woman was in a post-surgical delirium and was extremely combative, trying to hurt herself, her husband and staff. After trying every other non-invasive method we ended up holding her down and giving s/c Haldol to calm her down.

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If they are confused, and their legal next of kin or guardian consents for them, you can sometimes sneak oral meds in by crushing them and putting them in pudding, 15 mls or so of their favorite drink, oatmeal, etc. Injections are a bit tougher. I don't feel comfortable giving advice because each situation is different, and much would depend on how crucial the medication is to the overall goals of their care.

Being confused is not the same as having been declared incompetent. Just because a patient might be confused doesn't necessarily mean that her or his next of kin or guardian can give consent.

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Specializes in Hematology-oncology.
Being confused is not the same as having been declared incompetent. Just because a patient might be confused doesn't necessarily mean that her or his next of kin or guardian can give consent.

Right, I understand your point Chare. Like many aspects of medicine, I suspect this issue is different from state to state. In the state within which I reside (Ohio), legal next of kin can and do consent for a wide variety of things for confused patients who have not been deemed incompetent. They consent for blood products, colonoscopies, surgeries, admission to skilled nursing facilites upon discharge, and code status. If a confused patient will willingly take a b/p med crushed in pudding, her b/p is 185/90, and the family member wants her to take it....that feels like a win win. That doesn't mean I'm going to hold her down and force the spoon in her mouth.

Injections are more of a grey area because they cause pain. That's why I don't feel comfortable giving advice for administering injections to unwilling, confused patients on a public forum where nurses practice in many different states and countries. At my hospital, in these types of situations, ethics and legal is generally involved.

One caveat. In my state, a living will/advanced directive trumps a legal next of kin for code status.

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In my State, even in psych with a legally, fully committed patient, we have to have full court ordered meds before we can give ANYONE meds against their will.

Period.

A TDO or a commitment is not even enough. Has to be a separate court hearing specifically for specifically listed meds.

ETA: Chemical "restraints" have different rules, i.e. in psych we can hold a confused, psychotic, physically combative patient down, if they are risk to harm themselves, and give IM Geodon without consent because of laws governing the patient's own imminent personal safety. Otherwise, I'm just speaking about a patient refusing routine, prescribed meds. They have that right unless court-ordered.

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Right, I understand your point Chare. Like many aspects of medicine, I suspect this issue is different from state to state. In the state within which I reside (Ohio), legal next of kin can and do consent for a wide variety of things for confused patients who have not been deemed incompetent. They consent for blood products, colonoscopies, surgeries, admission to skilled nursing facilites upon discharge, and code status. If a confused patient will willingly take a b/p med crushed in pudding, her b/p is 185/90, and the family member wants her to take it....that feels like a win win. That doesn't mean I'm going to hold her down and force the spoon in her mouth.

[...]

Are you seriously suggesting that the next of kin of a person not declared mentally incompetent, who is awake and alert but confused, can sign a surgical consent for the patient? Presumably against the wishes of the individual in question?

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Specializes in Hematology-oncology.

I'm not saying surgery should be done against a patient's wishes. I'm saying that a confused person inherently can't make an informed consent. Obtaining consent is outside the scope of nursing practice, but it is within scope to question whether a patient actually understood the risks and benefits presented to them. Delirium and fluctuating mental status are the issues we see most often in the inpatient setting I practice in. Each case is different. Any nurse can consult ethics if they feel there is an issue. Often psychiatry is consulted as well. Here are a few links.

The informed consent process in older patients who developed delirium: a clinical epidemiologic study. - PubMed - NCBI

https://depts.washington.edu/uwmedres/pdf/hospitalist/Decisional_Capacity_and_Informed_Consent.pdf

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