Right to refuse vs Neglect

  1. OK....hypothetical scenario:
    elderly woman with run-of-the-mill elderly-related health problems and compression fractures begins losing sig amount of weight due to not eating, some contribution from nausea
    ...PEG tube placed
    ...sent home with home care.
    ..Family and client indep with tube feeds.
    ...also taking some po nourishment....

    a week or 2 later:
    ok...client not taking much. at all, by mouth....and begins refusing tube feeds at home...is admitted for dehydration, then sent home....
    this is discussed with her and family...
    ...and nurse (NOT ME!!) who re-admits her to home care brings up neglect..tells them that if they stop tube feeds again she may need to call adult protective, even though the client is refusing tube feeds. "although i wouldn't do it, technically it's neglect."

    I feel that since the issue is the client refusing the feeds, there was not a neglect situation...any others care to toss in their 2cents?

    here is followup, but please don't let it color your input on the aforementioned scenario...
    she is doing ok...weight stable...mild infection at peg site, currently on ATB...She wants the peg tube out..PCP has told her that if she can maintain her weight with po nourishment only, he will be willing to talk about removing the tube...
    Last edit by sunnygirl272 on Mar 4, '03
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    About sunnygirl272

    Joined: May '02; Posts: 4,131; Likes: 91
    home care nurse in a county-based certified home health agency, agency wound care guru for the agency


  3. by   bagladyrn
    My thought, though I'm not sure of the legalese, would be that administering feeding to a competent adult who is refusing them (in essence force feeding her) would constitute battery. I guess the question is whether or not this woman has been judged incompetent to make decisions regarding her own care.
  4. by   louloubell1
    I agree with bagladyrn. Unless the pt has been judged to be incompetent and unable to make her own medical decisions, then no one, not even her family, has the right to force care upon her, and they should not be made to feel as though they are abusing her for that.
  5. by   wv_nurse 2003
    Well I agree with the above statements-someone needs to intervene NOW--before the family is put in a situation where they have to make decisions for the patient--I envision a scenario where she takes enough po to get the tube out--then stops, and refuses to have it placed back---eventually she will become less responsive, and the family will be asked about treatment. She needs educated about her rights to refuse treatment, and needs a very specific advance directive--as well as a MPOA who is well aware of her wishes and willing to make those tough decisions to follow them.
  6. by   sjoe
    bag and vw are right. this woman needs to complete her advance directives, to protect herself and all around her.
  7. by   hoolahan
    This is one of those really sticky situations.

    First of all, the first mistake as I see it is that she did not really have an informed consent, b/c if it was not her wish to have a feeding tube, she never should have consented to it.

    For that reason, I question whether there is some dementia going on or not.

    Also to answer your question is that neglect? yes, it is self-neglect. We can refuse to take pt's back onto homecare services for non-compliance, and basicaly the woman is not complying w the Rx plan.

    Should she have to comply? No, and I agree it may be battery.

    However, why on earth would someone be losing weight w "run-of the mill" health problems? And why would one require a feeding tube for that?

    As for an APS referral? I feel that is completely appropriate. You guys have non way of knowing for certain if this woman 1) is really competent. We have all discivered the occasional pt where on the third visit they say/do something that makes the light bulb go on over yur head and say what the....you-know-what, and 2) if is is not cabaple of truly making an informed decision to refuse fluids even, then yes, the family is negligent.

    B/c you can't know for sure, then I think it is apprpo for the agency to either have a MSW referral or refer to APS for an eval. I have referred pt's to APS who neglect themselves. Had one lady who was sitting in her own stool for 3 days b/c she was unable to get up and get to the BR, coulodn't transfer self and lived alobne. She refused to go 911, as she was obviously discharged before she was ready. We had tried to reach her for 2 days, on the third day I agreed to do the cold visit and found her like that. She would not allow me to call 911 to get her back to hosp, so I told her I was notifying APS, she was unsafe, etc... She did I am told allow a friend to call 911 right after I left.

    Sometimes these pt's, and maybe not your lady, but the one I described , are the first ones to cry, the visiting nurse came and she didn't do one thing to help me.

    I think your lady needs a psych consult to be sure she is competent to make this decision, as it seems rather drastic for routine age-related health problems.Maybe she is severely depressed, or has ca of the brain, who knows??

    But yes, covering your but is never a bad thing.
  8. by   kids
    we need a standing ovation smiley...I want to be able to think just like Linda (and a couple of others) when I grow up!