Is this ethical?

madricka, BSN, RN · Oct 31, 2016

I don't think a guardian/POA can dictate when a woman sleeps or not. It's more about medical decisions, end of life care, treatment choices -- but I don't think it's about daily habits. What's next, are they going to say when she can/cannot have a BM or what kind of pudding she can have? The woman may have dementia but she is still a person and we must support her autonomy as much as possible. Forcing a person to stay awake if they are legit tired is just plain cruel. Having sleep/wake or day/night flipping is not uncommon in institutions and elderly people (esp with dementia). But if the woman is 90, has dementia and cancer -- let the woman sleep! Forcing her to stay awake might also cause her to be more agitated and less cooperative with other treatments (understandably!).

Bottom line: advocate for her autonomy, she is still a human being in there and deserves a bit of respect.

cyc0sys · Oct 31, 2016

I understand your dilemma. I have a similar situation at work. We have an elderly woman with advanced dementia that has sleep cycle reversal. The family has tried to engage her during the day with activities but no light therapy or serious behavior modification.

She sleeps most of the day and gets up frequently at night which wouldn't be a problem if she didn't require a walker for an unsteady gait. I approached the family about getting the Dr. to prescribe a sleep aid so we could try some sleep training for a few weeks and they made it sound as if I was suggesting a chemical restraint.

My primary concern is her safety as she is a high fall risk considering the circumstances. My secondary concern is the disruption of her sleep cycle as it most likely leads to generalized fatigue and accelerates the disease process. Evidently I lived in a 'Right to Fall' State so the staff isn't really concerned with trying to make any changes.

madricka, BSN, RN · Oct 31, 2016

We've used melatonin with great success in hospital with our elderly patients with dementia. They don't get snowed like they do with traditional sedatives and don't qualify as a "sedative" so families seem more comfortable with it. I can't link research here but it does exist if you search for it.

bbyRN, BSN, RN · Oct 31, 2016

When society, the legal profession, and POA's make it possible for every patient or resident to have a one-on-one caregiver 24/7 or at least really robust, well funded activities teams, then maybe there can be an "ethical" question. "Hypothetical" question as the OP wrote? This is not hypothetical; it happens, though most family/POA's have some understanding of their 90yo's and the limits of caregivers and healthcare systems such that they make a request but do not to make a big deal out of napping and other behavior (not "behaviors" but behavior in the common meaning of the word.) Sarcasm: let's amp up the 90yo so that this pt/resident becomes a fall risk and then have to answer to the POA, the facility, the State, etc for falls. No, it's not one or the other, but too many families and professionals/administrators create these either/or situations with debilitating effects on good aides, nurses, and physicians.

Nerd eNurse, ADN · Nov 1, 2016

If the patient is competent she makes the decisions. If she is not then I would talk to the POA and suggest that she made it to 90+ so why argue with success... if she wants to nap by golly she should be allowed to nap!

Been there,done that, ASN, RN · Nov 1, 2016

The power crazed POA would need to get the providers order to deny the LOL her much needed nap. If the deprivation of an effing nap was ordered, I would require the POA engage her to prevent the effing nap.

HealSpec · Nov 2, 2016

In my so far limited experience, this looks like an environment problem.

Where is this patient? Is it a hospice or LTC where she's basically in her "home" and the POA has turned into a PITA?

Or is this a psych setting, where therapeutic milieu is sacred above all, and she wrecks and decks it if she's not kept awake? Even as a new nurse, I've asked the oncoming shift to "please keep this patient up today, they were awake all night having behaviors, their roommate hasn't slept a wink". I wouldn't dream of doing this at a hospice, but in an acute dementia ward? Absolutely.

Either way, if you're at the point of considering it an ethical concern, this patient isn't doing well where she is, and it's possible that you're looking at a med adjustment, transfer, or discharge to somewhere that can work with her cognitive stuff more easily.

dspkfm · Nov 2, 2016

At 90 she does not have long to do what she wants to leave her alone and let her sleep.....How dare you tell her when she can and can't sleep......she is like a baby they sleep most of the 24 hour cycle......so let her stay up and watch TV at night.......

dec2007 · Nov 2, 2016

Power of Attorney only covers legal and money stuff.
legal Guardian controls health.
two different legal documents.
how are you supposed to keep them awake? Takzer?

No, there is also a document called "power of attorney for health care" which is to appoint someone else to make your medical decisions in the event you are unable to do so yourself.

dec2007 · Nov 2, 2016

And regarding the original question, I think it is highly unethical, but almost always the case, that we follow the wishes of the family rather than the patient. Patients aren't always vocal about their wishes, so the family has become the "customer" we seek to "satisfy".

FranEMTnurse, CNA, LPN, EMT-I · Nov 2, 2016

I too say it's unethical and also abusive. At 90- years old, she has earned the right to nap if she wants to any old time of the day.

Nerd eNurse, ADN · Nov 6, 2016

At 90 she does not have long to do what she wants to leave her alone and let her sleep.....How dare you tell her when she can and can't sleep......she is like a baby they sleep most of the 24 hour cycle......so let her stay up and watch TV at night.......

Another important factor is what was her norm... did she work night shift for 50 years?