What are your personal standards when a patient "refuses care"

ArtClassRN, ADN, RN · Dec 17, 2015

"It depends"

Can range from "Fine, have a nice day," to getting restraints.

Farawyn · Dec 17, 2015

Seconded. It depends.

Just make sure you document your butt off.

NOADLS · Dec 17, 2015

It doesn't fall on me, but I am the one who has to educate the floor nurses to document properly if a patient refuses care. It isn't good enough to simply state that the patient refused care. Keep in mind I work in LTC. The standard is higher for us than it is for a hospital.

loriangel14, RN · Dec 17, 2015

I don't argue but I will document and look for a solution if it's ongoing. You can't just walk away and never bother. With some demented patients they find showers particularly terrifying and you have to accommodate. Sometimes family can help. If someone is compus mentus it's harder to deal with.

dudette10, MSN, RN · Dec 17, 2015

It depends on so many things: what is being refused, the reason, the patient's mental status, etc. I generally spend quite some time educating or cajoling before I give up.

I did have a someone come up to me in the cafeteria one day and say, "I don't know if you remember me (I didn't), but you spent a lot of time explaining the angiogram to me. You also encouraged me to reconsider having it." He apparently was refusing the procedure prior to my being his nurse. He finished by saying that he did have it, and he thanked me again for taking the time to talk to him about it.

I remember him if I'm having a particularly bad day, and a patient of mine is refusing something or other. Sometimes I just want to throw my hands in the air, but then I think of him, and I give it a go.

Others have a different approach, I've noticed, especially phlebotomy. The patient needs only to shake the head once, and the phoebes are outta there so fast with a perfunctory call to the nurse. But, then again, they'll use any excuse to skip draws, including lying about patient availability (I've caught that lie two times and reported it.) PT/OT is usually consistently persistent because encouragement is a necessary part of their work.

DesiDani · Dec 17, 2015

You mean a sneeze doesn't count as a refusal í ½í¸? Yes I do believe that if you explain things they may feel better about it

Farawyn · Dec 17, 2015

You mean a sneeze doesn't count as a refusal Ã*Â½ÃÂ¸Â? Yes I do believe that if you explain things they may feel better about it

What does this mean?

quiltynurse56, LPN, LVN · Dec 17, 2015

My answer is also that it depends. I work LTC so it may or may not be obvious, though we are to get three no's before we chart it as a refusal. I have had a couple of times where a resident would tell me why when I asked and that is very helpful in their overall care.

DesiDani · Dec 17, 2015

I tried to use my phone's emoji. Major fail!

annie.rn · Dec 17, 2015

I have found that with a few of our "difficult" pt.s that end up with us long term (due to any or all of these: homeless, unfunded, psychiatric diagnoses, placement issues) staff get in the mindset of "once refused, always refused". I think the staff feels less accountability toward these pt.s b/c of their social situation and lack of advocacy.

I was told in report that one of our long term patients was refusing "everything but his Dilaudid". (Said facetiously, of course). He had not had vitals in over 24 hours due to refusals and he's a pretty medically complex guy. (DM, Dialysis, Anemia, htn., etc.) His socks were filthy and he had obviously not had his feet assessed despite having a diabetic foot ulcer.

Anyway! Seems like no one really tried too hard to get him to allow these things. It was easier to pass on the refusals. Makes the charting easier, right?

Well, I made a point to spend the first few hours of the shift getting to know him. I discovered he liked music and really lit up when talking about it. He had some of his music recorded online and during my lunch break I found it on the internet and listened to it. When I came back from lunch, I discussed it w/ him. He was shocked that I had actually listened to it.

After that, I had no issues w/ him and he refused nothing. He even let me look at his feet despite telling me he was really embarrassed to show his feet.

Of course, it is not always this easy but I find that if you come at it from a place of respect and don't force too much at once, you can usually reach a mutually acceptable decision.

When all your best efforts fail, document what you did in attempt to get the pt. to comply. Not just the refusals.

Also, document that you explained to the pt. the possible negative outcomes of his/her refusals.

RunBabyRN · Dec 17, 2015

I agree it depends. I am currently in outpatient care, and I have more time with my patients than hospital nurses do, so I explain the risks of their decisions (like one of my patients who irrigates his catheter daily with tap water, when I can get him sterile water or saline). I also do telephone triage, so when I am trying to urge a patient to go to the ER, and they want to give me a 15 minute saga about how they hate the ER, they did XY&Z to them, etc, I have to tell them that I would not send them if I didn't think it was necessary, there is a risk of bleeding out/sepsis/etc if they do not go, and all I can do is document that I strongly urged them multiple times to go to the ER, and I explained to them that there is nothing we can do for them in the clinic.

I agree- document, document, document.