concealed medicines?

[FROGGYLEGS]

This is a simple question and I almost feel silly asking about it, but it just won't seem to go away. At any given time it seems like I have at least one patient this applies to.

Can a nurse ever give medication to someone who won't accept it by way of concealing it in food? Does it make any difference if the patient is confused or demented?

My current example is absolutely and adamantly refuses any and all meds. Other staff report that the only way for the pt to accept meds is by crushing them and placing them into his food at mealtime. I don't feel comfortable doing that so I just offer repeatedly and sign as refused. Looking at the MARs at the end of the month shows that he always refused my meds and on very rare occasions the meds offered by other nurses. I am just a bit worried that it reflects poorly upon me. I don't want it to seem like I'm just too lazy to get him to take them. I have tried everything and he just won't do it. I really do believe the others are correct; he won't take them unless they're hidden.

Thanks for any input. :)

[Lawnurse]

and I know it isn't an excuse, but when you have worked on the same job for almost 25 years, under the SAME DON for MOST of those years, and you have been told, "It is your responsbility to make sure that every person gets every dose of medication they have ordered.", then it's just part of what you do.....do everything you can to get this medicine given.

LPN1974, I understand what you are asked to do is a very difficult job. However, any lawyer would *tear you to SHREDS* with a reasoning like this.

Remember, only YOU can protect your license.

[Speculating]

i was going to post exactly what elkpark stated.

it's clearly stated in the patient's bill of rights that they have the right to refuse treatment, even medicinal.

also, i too have felt the frustration of me being the only one to circle a med as being refused by the pt.

yet i also always felt deceitful if i tried to sneak it in otherwise.

even when i informed their doctors of the refusal and they would give an order to put it in pudding/ice cream, i still knew it was wrong and my conscience got the worst of me.

the only time i have ever given a med against a pt's will is if it was an emergency, i.e., haldol im.

yet ALL the other nurses had no problems mixing it w/a pt's food of choice....could never bring myself to do it....even if i do understand why they're doing so, i felt it was a betrayal of their wishes, and therefore, their trust.

what i would like to know, is if the person is severely demented and refuses meds, would their legal guardian be able to consent to us giving them meds in food? not the md, but the legal guardian who makes all the decisions on behalf of the patient? elkpark?????

leslie

I got this one. I'm not lawyer, but I slept at a Holiday Inn. I very comfortable in telling you that's perfectly legal. I've never had that exact situation but given that scenario and the fact that the Guardian can give you consent to do brain surgery some pills in some pudding is fine.

[Lawnurse]

The "severely demented" part is key.

This person is not competent to consent or refuse.

When a pt's not competent, his/her guardian assumes this role.

So, yes, it follows that the legal guardian could consent to the meds, as long as there is no conflict of interest - then it would get complicated. Say, for example, the legal guardian is responsible for putting the pt in his/her present state, and is on trial for that. Guardian needs pt to be kept alive until guardian's trial is over so that guardian is charged with the beating instead of manslaughter/murder.

[dbsn00]

I work in LTC - if the patient refusing is confused or has a psych. dx. we get a MD order to crush & mix with meals & have legal guardian/POA give permission for this. If they are alert & orientated I ask why they're refusing, try to explain the importance of the meds & contact their MD after documenting. If there is no legal order written for concealing meds in food you are abusing the patient, possibly restraining them too depending on the medication. I have several resident who are paranoid schizophrenics, not only do they refuse their meds they try to stop you from giving them to others also ("it's POISON, don't take it!!!"). Our DON says the same thing - "it's your responsibility..." so be responsible. Document, contact the MD & get a written order. No lying, no risk to licensure, & the patient gets the meds they need. I also think it's interesting that on my days off my resistive patients suddenly take ALL their meds...

[elkpark]

Please also keep in mind that, when we talk about "legal guardians," we are talking about someone who has been adjudicated incompetent in a court of law, and a guardian appointed by a judge. Just being demented or retarded, even severely so, does not automatically invalidate a person's civil rights.

We all know that family members often use the terms "legal guardian" or "guardian" when what they really mean is they have been making sure Grandma's bills get paid. People who are actually a person's legal guardian understand the difference and will be happy to show you the court order that says they are the guardian! You should never medicate anyone (or do anything that requires consent) on the say-so of a family member without knowing for sure the patient's legal status, and that the person you are speaking to is actually legally able to give consent for anything. What I have seen over the years is that, typically, a copy of the court order appointing the guardian, or a copy of the DPOA for healthcare, is on the patient's chart; usually right at the front of the chart.

Even when a competency eval is done by a psychiatrist, it is not the psychiatrist who makes a person incompetent. The psychiatrist's eval is one piece of the evidence considered by a judge in ruling in a competency hearing. Only a judge can make someone "officially" incompetent. If the doc's eval is on the chart that the person is not competent to make decisions, that still isn't legally binding until a judge has ruled.

The other situation in which a family member (or other individual) would be able to give consent for the patient to be medicated involuntarily is the existence of a valid DPOA (durable power of attorney) for healthcare. DPOAs play out a little differently in that the DPOA takes effect at any time the person (patient) is unable to make decisions for her/himself or unable to communicate those decisions. In the case of a DPOA for healthcare, whether or not the patient is able to make or communicate decisions about treatment is a medical decision (i.e., made by the physicians treating the patient). The DPOA is also different in that it "comes & goes," that is, it takes effect at the time the patient is unable to make or communicate decisions, and then, when/if the person is once again able to make and commuicate her/his own decisions, it loses effect (until the next time ...) and the person goes back to making her/his own decisions. Once you've been ruled incompetent by a judge, you're incompetent forever (unless you go to court and and convince a judge that you're not incompetent anymore).

As I said before, I do understand the frustration of trying to medicate seriously demented or retarded (or paranoid or delusional, etc., etc.) clients, because I've been there, too (in acute care settings, but the same issues). And I became v. familiar with all the legal issues involved when I was doing psych consultation liaison work for a few years at a big teaching hospital -- we did lots of competency evals (that was the first thing the treating docs would ask for when a person refused treatment), and we worked closely with the hospital legal counsel about the ins and outs of all this, so I became v. familiar with how all this works. And then, more recently, I've been dealing with this as a state and Federal surveyor/investigator ... As you can see, it's a pet "cause" of mine, because it is so poorly understood, even by lots of healthcare professionals.

Instead of just illegally medicating people involuntarily, staff (administration?) in LTC and residential facilities that are treating seriously demented and MR and MI people need to be more aggressive about encouraging the family to go to court and get the person declared incompetent (if that is, in fact, appropriate) and get a guardian appointed. Then everyone can be "legal." (And "legal" is good ... :) ) Until that happens, the patient has the same legal right that you or I do to make her/his own choices about accepting or refusing treatment! And there are lots of problems besides just meds with people who really are not able to make decisions for themselves but have no one legally authorized to make decisions for them ...

Sorry for running on so long, and, again, I'm not criticizing anyone here -- I understand that lots of people don't really understand how all this works. Hope I'm being somewhat helpful.

[Speculating]

Please also keep in mind that, when we talk about "legal guardians," we are talking about someone who has been adjudicated incompetent in a court of law, and a guardian appointed by a judge. Just being demented or retarded, even severely so, does not automatically invalidate a person's civil rights.

We all know that family members often use the terms "legal guardian" or "guardian" when what they really mean is they have been making sure Grandma's bills get paid. People who are actually a person's legal guardian understand the difference and will be happy to show you the court order that says they are the guardian! You should never medicate anyone (or do anything that requires consent) on the say-so of a family member without knowing for sure the patient's legal status, and that the person you are speaking to is actually legally able to give consent for anything. What I have seen over the years is that, typically, a copy of the court order appointing the guardian, or a copy of the DPOA for healthcare, is on the patient's chart; usually right at the front of the chart.

Even when a competency eval is done by a psychiatrist, it is not the psychiatrist who makes a person incompetent. The psychiatrist's eval is one piece of the evidence considered by a judge in ruling in a competency hearing. Only a judge can make someone "officially" incompetent. If the doc's eval is on the chart that the person is not competent to make decisions, that still isn't legally binding until a judge has ruled.

The other situation in which a family member (or other individual) would be able to give consent for the patient to be medicated involuntarily is the existence of a valid DPOA (durable power of attorney) for healthcare. DPOAs play out a little differently in that the DPOA takes effect at any time the person (patient) is unable to make decisions for her/himself or unable to communicate those decisions. In the case of a DPOA for healthcare, whether or not the patient is able to make or communicate decisions about treatment is a medical decision (i.e., made by the physicians treating the patient). The DPOA is also different in that it "comes & goes," that is, it takes effect at the time the patient is unable to make or communicate decisions, and then, when/if the person is once again able to make and commuicate her/his own decisions, it loses effect (until the next time ...) and the person goes back to making her/his own decisions. Once you've been ruled incompetent by a judge, you're incompetent forever (unless you go to court and and convince a judge that you're not incompetent anymore).

As I said before, I do understand the frustration of trying to medicate seriously demented or retarded (or paranoid or delusional, etc., etc.) clients, because I've been there, too (in acute care settings, but the same issues). And I became v. familiar with all the legal issues involved when I was doing psych consultation liaison work for a few years at a big teaching hospital -- we did lots of competency evals (that was the first thing the treating docs would ask for when a person refused treatment), and we worked closely with the hospital legal counsel about the ins and outs of all this, so I became v. familiar with how all this works. And then, more recently, I've been dealing with this as a state and Federal surveyor/investigator ... As you can see, it's a pet "cause" of mine, because it is so poorly understood, even by lots of healthcare professionals.

Instead of just illegally medicating people involuntarily, staff (administration?) in LTC and residential facilities that are treating seriously demented and MR and MI people need to be more aggressive about encouraging the family to go to court and get the person declared incompetent (if that is, in fact, appropriate) and get a guardian appointed. Then everyone can be "legal." (And "legal" is good ... :) ) Until that happens, the patient has the same legal right that you or I do to make her/his own choices about accepting or refusing treatment! And there are lots of problems besides just meds with people who really are not able to make decisions for themselves but have no one legally authorized to make decisions for them ...

Sorry for running on so long, and, again, I'm not criticizing anyone here -- I understand that lots of people don't really understand how all this works. Hope I'm being somewhat helpful.

Don't be sorry for being long BRAVO and thank you, but I do believe we should get some CEU's for that. :Melody:

[CHATSDALE]

if you do not have a doctors order AND the consent of the legal guardian then what you are doing is against the law...and let me tell you getting up on a witness chair and saying that they don told you it was your responsibility to get them to take the meds you can bet your license they will make the statement 'oh my goodness i didn't mean that'

i know that there were things that were done in the past which is absolutely illegal now

at ne time nurse would put med in the patients mouth and hold their nose until they had to swallow it in order to breath...do not try this unless you want a striped suntan

i know that if you have many patients to get meds into one or two of these will get you so far behind you feel like you will never catch up...but don't do anything that you can't explain legally

and do not take the route that some of the other nurses do who initial a mar no matter whether a patient takes it or not...that is also illegal and poor nursing..

[Speculating]

A DRS ORDER DOES NOT SAVE YOU! Do the smart thing and you'll be fine.

[Lawnurse]

Well said elkpart, Chat, and speculating.

Has anyone who is actually dealing with this situation at work explained to the DON that is is highly likely other nurses are either lying in the charting or forcing meds illegallly?

plaintiff's lawyer: You never forced meds on the patient, did you?

YOU: no, never.

plaintiff's lawyer: and other nurses were able to administer all of the meds without forcing them - every single time?

YOU: I can't say for sure.

plaintiff's lawyer: Then how were the meds getting administered?

YOU: I don't know.

p's l: you don't know? you never asked one of the other nurses how they were able to manage a 100% sucess rate - whereas you couldn't?

you see where this is going...you either look bad because

1) you didn't bother to ask another nurse how they were able to do it, or

2) you end up admitting that you assumed other nurses were forcing meds and you didn't even ask that nurse or bring it up to the DON.

[LPN1974, LPN]

Okay....just an update from me on this matter.

You all have CONVINCED me thoroughly and absolutely.

Especially ellkay. I will NOT be hiding any more meds in pudding.

I have come up with my own plan on what I think I should do.

I am going to offer these people who refuse their meds, the medications 3 times, during the time I am in their home passing the meds. If they don't take it the first time, I'll go back 2nd and 3rd times, at spaced out intervals, that way I have made a reasonably good attempt to let them take it on their own. If the person refuses, they will just have to refuse it.

Maybe I can offer them a small cup of juice or punch with their meds. Maybe THAT would encourage the refusers to take it, ya think?

I will work with them and do my best to try to get them to take it, but no more concealed meds. And if they refuse it will be charted appropriately, which I do that anyway. I will also talk to the other nurses and see how things are going for them.

Do ya think this is reasonable?

I have NOT been able to talk to my DON like I wanted to. She wasn't there yesterday or today when I got to work. {Her son and daughterinlaw just had a baby, so I think she's with them.}

And I'm off next two days again, so no contact with her those days either.

Then the weekend is coming up.

Anyway, you all have convinced me. I won't conceal anymore meds.

I want to thank all of you for being concerned enough to get me straight on this matter. I have worked too hard to lose my license now.

For the time being, that is what I will do.

Maybe I will get to see my DON next week and bring up these concerns with her, about people who refuse, and the line of thought that maybe we should get guardian consents on what to do in the event that someone refuses their medications and how they prefer us to proceed, the consequences of refusal and all.

For chatsdale......I have never held someone's nose to make them swallow. A person could be caused to choke like that. So that is not a concern for me.

Anyway, thanks again, all, maybe next week I will finally make contact with the DON.

BTW.....these people we take care of DO have guardians.

They have the right to make certain decisions in certain areas of these people's lives, I know that much. I'm not a lawyer, of course, so I don't know all the legalities of how far these guardianship rights go in my state, but I will try to bring that up with the DON.