Moral Dilemmas: Two Scenarios - What would you do?

Nurses General Nursing

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[color=#808080]hi, i'm new here (first post) so i hope i'm posting this in the right forum!

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[color=#808080]i realize that in nursing we will encounter a lot of grey areas when it comes to ethical/moral issues but i'm hoping y'all can help me with two scenarios in particular.

[color=#808080]1) we have a resident "paula" in our ltc facility who is orientated x3 but has what a psychiatrist has termed a drug-induced paranoia that has been going on for over a month. the doctor tells us to be patient and it will wear off therefore he chose not to send her to a psychiatric facility. she will often refuse to eat saying we are trying to poison her and is refusing peri-care and won't wear an incontinent system although she is frequently incontinent. she wants to smell everything (blankets/clothes/towels, etc.) before they come in contact with her and will often refuse to use them or make us get another clean one. she will no longer sit in a lounge/recliner chair and is refusing to get into bed at night (saying it burns her) so she sometimes sits all day and sleeps through the night in her wheelchair. she has parkinson's so her mobility is impaired. when we try to gently coax/reason/plead/be firm with her she says she pays to live in this home and she knows her rights and we can't force her to do anything. i understand that she has the right to refuse but we have a responsibility to care and this whole situation leaves me feeling very inadequate as a nurse. we, lpns and rcws on the floor have addressed our concerns to our supervisors many times but there has been no real response other than to "be patient with her." that would be understandable for a few days but this seems to be an ongoing issue and it's very unhealthy. either we neglect to provide the care necessary or we do cares against her wishes while she pushes us away -this does nothing to improve her paranoia that we are trying to kill her. honestly, i feel she should be in a psychiatric facility where they are better able to monitor, assess, address these issues with a comprehensive care plan, but that's not my decision to make. depending on the rn in charge we will either be told to let her refuse or to force her to comply. our interventions are very inconsistent and that only makes the situation worse.

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[color=#808080]2) another resident, "mary" is unable to ambulate herself and depends on staff for total care. she is orientated x3 but her judgment is impaired. she frequently asks for the cordless telephone to call her daughter, but her daughter has indicated that her mother was abusive and she doesn't want her mother calling her. she visits occasionally on her own terms. mary knows her daughter's phone number and where she works. when she asks for the phone we (staff on the floor) are told to tell her that the phone isn't working/can't be found/is charging, etc. this could go on for the better part of a shift and mary knows she's being lied to... she'll say, "why are you doing this to me? why won't you let me use the phone?" mary suffers with depression and i realize it would be hurtful to tell her that her daughter doesn't want to be contacted. (in fact, i'm guessing her daughter doesn't want us to say that to her and would rather we distract/lie to her.) but that leaves us in a very uncomfortable position: lying/denying the phone to someone who knows very well what is going on.

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[color=#808080]can you offer any insights here? what would you do?

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[color=#808080]i realize these aren't black-or-white issues but feel very uncomfortable with the care plans (or lack thereof) for these individuals.

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[color=#808080]thanks, michelle

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Specializes in ER, ICU, Medsurg.

My first question regarding #1 is if this has been going on for a month, when was the last time the issue was addressed with the doctor. If I was working there I would discuss the situation with the doctor again explaining that it has been over a month and the resident is still displaying paranoia. Depending on the attitude of the physician I would ask for a change in medication or a referral to mental health. (again depends on the physician, some you can/some you can't suggest things to).

As for 2, Has anyone discussed with the daughter that you are not able to "lie" to her mother? That this is putting the staff in an awkward position? I would be uncomfortable with this. Residents need to be able to trust their caregivers and this woman knows she is being lied to. The daughter needs to make a more considerate decision on how to handle the situation. If the mother was not in LTC and was in the comfort of her own home, how would the daughter handle having her mother call her? Albeit you are the residents caregiver but you should not be put in the middle of family dynamics.

Good luck, I'm not in LTC and this is JMHO. I'm sure you will soon get more responses from experienced LTC nurses.

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Thanks Pharmgirl! The first lady has been seen by her neurologist and he discontinued the medication that he thinks is causing the paranoia. I'm not in a position to talk to the doctor myself as I am an LPN who only works 3 shifts/week. The RN supervisors are the only staff who deal with the doctors. I guess this applies to the second scenario too. I agree, ideally this would be discussed with the daughter but I am not in a position to pick up the phone and call her -this would be considered inappropriate. Again, all issues of this sort should be addressed to the RN supervisors who are to contact the family, etc. Unfortunately, I don't feel the RNs feel this is a big deal -they don't provide immediate care and aren't the ones who have to lie to the resident. If it were a smaller facility, or I was a full-time staff member I might have more say in these things but right now I feel like we (those on the floor providing care for these residents) are being ignored.

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Specializes in Burn, CCU, CTICU, Trauma, SICU, MICU.

Patient #1 - needs to be further evaluated. They can't just let her sit there, change the meds, give you PRNs, etc... how awful is it for her to be paranoid, upset, anxious, etc... and just be told to "wait it out" - not fair to you or her!

Patient #2 - It isn't my job to spare a patient from family drama and I am not going to lie to them. Our lying to patients does nothing but allow their family to skip out on the responsibility. "I'm sorry, but your daughter has requested not to speak with you. I cannot bar you from using a telephone (this isn't a prison, after all), but your daughter does not want contact with you at this time and you can do with it as you please."

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Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

Yes as above.

Patient no 1: needs to be re-evaluated. You cannot let a person sleep in a wheelchair all night, especially with PD. She can develop pressure sores, and it's not a proper sleeping surface. I would be quietly having a word with her family to ask another Dr to re-evaluate the patient.

Patient no 2: Do not get involved in family squabbles. Your supervisor needs to ask the daughter to tell the mother she does not want to speak to her. Never lie to patients. Tell her her daughter does not want to speak with her, but do not get involved in the argument. I would strongly support getting the daughter to speak directly to the mother.

I had a very similar patient like no 2, and the daughter was ALWAYS wanting us to make excuses so not to speak with her Mum, but I used to refuse. If you get involved in family squabbles, you will never hear the end of it, and when you are perceived as 'taking sides' (even if u aren't), you will get blamed - big time! I have been involved in enough family feuds in hospice and in mental health - best to say ur a professional and you want to stay neutral.

And your supervisor should NOT be encouraging you to lie to patients. In Australia we aren't allowed to do this under any terms, and it is not legal. Your supervisor should be made aware of this somehow. Lying to patients - about anything at all - is not ethical or legal.

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Specializes in ER, ICU, Medsurg.

Ditto Mskate!! Agree totally. Michelle, you probably need to sit down with case management or the RN supervisor or whoever is above the charge and discuss your concerns. Whether you are prn, pt or fulltime does not matter when it comes to the residents you are caring for. Have a discussion first with your charge and tell your concerns and offer constructive suggestions. If those suggestions are ignored, then I would go above her. Tell her superior that you discussed it with the charge nurse but are still having concerns. Don't whine, be objective and offer solutions. No need to chuck the charge nurse under the bus, just explain to management that you have true concerns about the care these residents are receiving.

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Thanks for the advice and encouragement everyone. I really need to develop a backbone it seems! I'm in a new facility and I'm still in my probationary period so it's very intimidating going against the wishes of my supervisors. I don't want to come across as someone who is always raising issues but I know I have valid points.

As for the lady who refuses to get into bed at night are we able, as nurses, to force her into bed? It sounds horrible but that is what it comes down to. We'd need to do a 2 person transfer, put her in bed and put the rails up. If someone's judgment is impaired do we have the right to over-ride their right to refuse?

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Specializes in Burn, CCU, CTICU, Trauma, SICU, MICU.

As for the lady who refuses to get into bed at night are we able, as nurses, to force her into bed? It sounds horrible but that is what it comes down to. We'd need to do a 2 person transfer, put her in bed and put the rails up. If someone's judgment is impaired do we have the right to over-ride their right to refuse?

This is always a touchy thing and determining medical incompetence can be difficult if they are still able to recognize "I am a patient in xyz tlc and you cannot make me do anything, i refuse care." It would be worth while to request a psych c/s to come and determine *in writing* their legal, medical competence. If they are deemed incompetent, you can contact their next of kin, explain the problems, lay out a plan of care and do things that aren't what she wants done. If she is determined to be able to make her own medical decisions, then you can't really do anything but *document document document*.

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Specializes in ICU, Telemetry.

I've had those on the floor that refused everything, even though it was medically necessary. See if you can get the social worker to get a guardian ad litem appointed, and get that person to have them either moved to a psych facility where they can get help or make the doc get on the ball with the meds. I don't know of any "drug reaction" that lasts a month and causes paranoia. This situation isn't fair for the pt, but it's really not fair for the other people living there, either.

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Specializes in LTC, Wound Care.

I would NEVER work in a facility where I am not allowed to contact the doctor or family myself.

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Thanks again for the feedback. The next time I am assigned to these patients I will definitely raise my concerns/suggestion and "document, document, document" when care is refused. If nothing is done to address the issues I will go move up the chain of command. I'll keep y'all posted if anything interesting develops.

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I have a resident like number 1. I don't know what I would do If I couldnt talk to the family. I'm an rpn (same as LPN) and we are resposible for calling and infroming the POA's. The family is now coming in to help us get this person to shower and eat. We have a hard time getting this person to change her clothes....so now when we are able to get her into the shower (still rare) we "accidently" get her clothes wet. Which she will then refuse to put on lol. Good luck and keep pushing. Trust your instincts!!

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