LTC ethical issues

Hi! I am a new nurse and just started working in a Long Term Care Facility. I am of course overwhelmed, as I am sure all new nurses are when they begin their careers. My preceptor certainly does not do much of anything "by the book". She has long abandoned universal precautions, and (as far as I can tell) does not ever assess her patients (she simply relies on the CNA to let her know if an issue arises and simply copies the information charted on previous shifts concerning patients whith edema, respritory issues that need monitoring, etc.). This, I realize, is going to be something that I run into anywhere I go. However, there is one issue that is bothering me more than any other. There is a resident on our hall who is a diabetic. According to my preceptor she once "bottomed out" and is now scared to death of it happening again. She is on a sliding scale (her bs runs quite high- usually over 320). She usually requires about 12 units of insulin at 1600 (according to her sliding scale). However, she does not ever want to be given this much. Every day it is the same routine (accoring to my preceptor), she needs X amount of insulin, but will insist that the nurse give her less. For example, if she needs 12 units she will insist that the nurse only give her 5. She is totally competent and in control of her own care. In order to avoid conflict, my preceptor will LIE to this woman about the amount of ilnsulin she is giving her! She will say "Well, your sliding scale calls for 12 U, but I'm just going to give you 5..." Then she draws up 12 units and gives it to her anyway. I know that once my training is over I will have to resolve this issue (obviously by getting the doctor involved). What I am struggling with right now is whether or not to report what my preceptor is doing to the DON. Everyone that I talk to (nurses in the area, etc.) advise that I just stay out of it. They seem to think that I would be courting disaster by reporting her. Please! Someone give me some advise! I really feel that I should say something...am I'm I just being naive?!

Usually in LTC settings, they have doctor's log book that nurses write down any concerns or problems with patients that needs to be dealt by doctor. Can you write down in doctor's book stating patient is refusing everday to receive 12 units of insulin due to this patient had hypoglycemic reaction and is requesting to receive less amount of insulin? That way doctor knows what's going on with the patient and he can adjust patients insulin? Is this the first time patient had insulin reaction or does it happen very often? If this happens often, then log in doctors book that patient's blood sugar has been running low.

Honestly, I don't think I would report her. When I was going thru orientation I saw a lot of really bad stuff. As long as it wasn't harming the pt. I just sucked it up and said to myself "I can't wait until I'm on my own." Once I got on my own I did things my way. She's wrong for what she's doing, but it sounds like the pt. isn't bottoming out because of it and the pt. is probably just worried for no reason. It's not right, but it's not hurting the pt. either. You'll learn a lot from other nurses as a new nurse, from some what to do and others what never to do. God bless on the decision you make.

What this nurse is doing is unethical. However, I would tread very carefully.

One alternative solution has already been mentioned; get the doctor involved. If the resident's blood sugars are running that high on a regular basis, then something is not working. Her medication regimen needs some tweaking.

I'll forgo commenting on whether you should report your preceptor. That's a tough call.

However, I wonder if you could gradually introduce better BG control with this Pt by first making sure the Pt understands that someone is actually checking on her reaction to the given insulin frequently. That way, perhaps some of her anxiety about bottoming out would be reduced. In other words, make it a priority to speak with her q 15 min for an hour after she gets her insulin. If she would tolerate additional sticks for accuchecks that could help ease her mind as well, and give a clearer picture of her reaction to all involved.

Then gradually move her toward the ordered ss dosage by demonstrating that the amount of insulin she insists on does not control her glucose. Rather than go straight to 12 units as the scale says, try to convince her to accept 6, then if that doesn't bring it down to acceptable levels, ramp up to 7, etc.

The combination of gradualism and encouraging her feeling of safety from frequent checks on her could move her forward.

Good point. I've found that many patients feel more comfortable with the treatment plan if they know someone will be watching them closely. One strategy is to promise to check on them at such and such time, then make sure you follow through and check on them at that time. Since you do not want to destroy any potential trust that you're trying to build, if you don't think a specific time is realistic, then give a window of time, stating that you WILL be in to check on her and make sure she is not low. Also, asking her about her symptoms when she does get low, and making a backup plan, sort of like contracting with her. Tell her "If you feel XYZ, put on your call light to let me know. We can give you a snack/glucose tablets to get your sugar back up.". Involving her in making a plan of action and showing that you take her concerns seriously and are knowledgeable enough to handle a low BS situation might make her able to relax a little of her vigilance.

Sometimes people just need to know that someone competent is watching out for them.

I would say something to your preceptor only. I would not have spoken to other staff members. Bring up the concerns you have with her in a supportive fashion if you can. Gently remind her patients have the right to refuse medications.

My pet peeve staff who will not tell patients they are receiving medications in puddings and such. This is also is a violation of patients rights.

springchicken - all in all, you are right, and your preceptor is wrong.

The reason it's a dilemma is more than just the collegial relationship with your preceptor/senior.

There is the medical need of the patient against her civil rights. How do you meet both these needs at the same time?

On a ethical clinical level:

Your preceptor is essentially compromising one wrong for two rights - but she is only doing this in the short term. This is long term care and the issues should be considered in a long term basis.

The difficulty in lying to the patient is clear - it's wrong. But in meeting her clinical needs there are two contrary issues:

1. a risk of chronic complications. (by not giving the full dose)

2. a risk of acute anxiety on each occasion of Insulin. (by asserting she needs the full dose)

Is it right for the nurse to avoid the acute unnecessary anxiety as well as achieve the diabetic control? Her actions meet both these need; but as stated - they are short term "solutions" that are repeatedly replied to a chronic problem.

There is a legal concept of 'reasonable' and ';best interests' - where in the short term management it might be considered 'reasonable' and in 'the best interests' to not cause undue anxiety in a patient where time and circumstances call for 'creative care' (I don't advocate lying to pts but sometimes not telling the truth is acceptable)

rngolfer53 is very right tho - this woman is in LTC - long term - and there's no reason why someone can't attempt to get to the bottom of why the patient is declining the full dose and seek to allay the fears by other means than decpetion.

The issue needs to be raised and discussed as the long term detriments of this is that the pt is not getting an honest account of her treatment - if she's getting the full 12 and believing it's only 5 and finding her BGL (BS, BSL, ... ) to be "ok" - then she thinks she's right to 'order' a reduced dose; and the nurses are placed in this dilemma - as you've raised.

I would support rngolfers suggestion and add to it that time needs to be given this lady outside of 'insulin' time to discuss her anxieties so she knows her issues are important and to gain a better understanding of why she is reluctant. This will help with the rapport with the woman and hopefully gain her trust to engage her in the trial interventions to accept the full dose.

On a legal professional level:

This nurse is commiting assault and, if the pt were ever to realise and make complaint, the nurse may find herself convicted of criminal charges and further having her license to practice compromised, if not revoked.

Couple different things. I would go about educating the pt about the need to follow the correct dose, the fact that you will monitor her, giver her a snack at hs, etc. If she refuses to follow the sliding scale....call the doc and let them know and get a new order or what ever. Chart, chart, chart. You do not need to let everyone know that xyz nurse does something else. I think this would be my first plan.

http://ezinearticles.com/?Covert-Administration-of-Medicines&id=915653

short article on covert medication adminstration. Perhaps you can print it off and give it to your preceptor.

These are some great ideas! It seems like common sense now that you mention it, to first get to the bottom of this residents anxiety before deciding exactly what my next step will be. I have only worked as an LVN for 4 days now, and being new it is so easy to be so "task oriented" that I forget to just use a little common sense when dealing with problems! I guess that is normal at first! What makes me so angry about this situation is that my preceptors deceptive actions are the reason that this situation is going to be so hard to deal with in the first place! The resident does feel totally justified in refusing her insulin, because she has been lied to so much and believes that a smaller amount is controlling her BS! I just want to tell her, "No...they have been feeding you a bunch of bull...!!" But...I could just imagine all the dramma that this would cause! I would probably be fired for not going to the DON first...