My patient does not comply.

[aricklefs]

I'm looking for advice. I have a post stroke patient that will not comply with sitting up to eat and is insisting on eating while laying down in bed. She has been educated many times of risks and is her own decision maker. She wants staff to leave food at the bedtime to snack on all day. What are our liability issues and what can we do? Should we have a staff stay with her? Have her sign a waiver?

[Lev, MSN, RN, NP]

You should not leave her snacks at the bedside. Document in as many places as you can that patient refuses to sit with HOB elevated for meals and that you educated patient about risks of aspiration. When she does eat, someone should be in the room with her. This should be documented as well. Talk to the doctor.

[jadelpn, LPN, EMT-B]

Have you asked her why? Is there something that is uncomfortable about sitting up in bed to eat? Is it something that can be remidied? If she is having speech/swallow see her, can they speak to her about it? Sometimes it has to do with not being able to sit upright without leaning to the affected side. Other times it is that patients get so upset when food/drink dribble out of the affected side. Occupational therapy can suggest things as well to make this easier on her. Document everything.

Is she on aspiration precautions? If so it would up to the MD to be sure that she follows them. What happens when you sit her up? She refuses to eat? Another thought is that all eating is done in a chair, and not in the bed. Again, need MD and support services help to comply with this.

This is something I would speak to the speech therapist about, the MD about.

[toomuchbaloney]

Are you in acute care? Rehab? LTC?

Is the woman living there or just staying for a specific period of time?

What are the provider orders relative to nutrition?

Does the woman have an increased risk of aspiration?

what has your management team said about this?

IF it were me and she is in rehab with an aspiration risk documented in her record I would refuse to participate in the unsafe behavior and make sure that my documentation reflected the specifics of the situation...especially that the MD and higher ups had been notified.

She will then be left with complaining that I did not provide her the opportunity to aspirate. Oh well.

[Been there,done that, ASN, RN]

Assuming she is competent, she can refuse any treatment orders. All you can do is document that the physician is aware and your teaching efforts.

Any liability issues are addressed within the gazillion admission forms.

In other words, she has a RIGHT to eat anything she wants, in any position.

[morte, LPN, LVN]

after all other evals, I would suggest psych. Does she wish to die?

[amoLucia]

Is there a documented swallow eval? I'm not sure that they could do it with the subject in a lying down position, but that would be fantastic.

Is the family aware? You wouldn't want the family to say that the staff allowed the pt to aspirate. Or that they withheld food and now the pt has lost weight. (Thoughts of those late-night TV advertisements for nsg home abuse/neglect with the dial 1-800 LAWYER info is running thru my mind.)

Everybody needs to be on the same page. I've worked places where non-compliant aspiration-risk pts signed a waiver (with family witnessing) so there was documentation that families WERE aware. And whatever approach is used, it should be care-planned.

[sharkdiver]

Assuming she is competent, she can refuse any treatment orders. All you can do is document that the physician is aware and your teaching efforts.

Any liability issues are addressed within the gazillion admission forms.

In other words, she has a RIGHT to eat anything she wants, in any position.

THIS! (emphasis added to quote by me).

One of my pet peeves is the term "non-compliant". By definition it implies that medical staff have some legal authority to require patients to follow their instructions, which except for extremely rare circumstances involving a court order, they do not.

Regardless of what you call them, doctor's "orders", or instructions from nurses or other medical personnel have no legal standing, and are effectively nothing more than recommendations and advice that the patient is free to accept or reject as they choose. In the vast majority of instances they certainly would be better off if they follow those recommendations and advice, but the bottom line is they have every legal right to refuse to do so.

Document the teaching and note that the patient chooses not to follow the recommendations.

On a final note, I'd recommend never using the term "non-compliant", especially when charting. A couple years ago we had a staff member receive a written reprimand when they did so and the patient filed a formal complaint that the comment was defamatory.

[Pepper The Cat, BSN, RN]

You can provide education, but you can't force people to comply. Just as a diabetic has the right to eat foods not recommended, or the heart pt who continues to smoke. Their life, their choice. Document, document, document; but you are not going to change them

[MunoRN, RN]

It's a competent patient's right to eat in whatever position they want, and it's our responsibility to ensure that the patient's rights are being honored.

In general it's not really possible for a patient to be non-compliant with their plan of care. Since the patient's plan of care is supposed to be based on the patient's wishes, preferences, beliefs, etc, if there is something in the plan of care that the patient disagrees with, then the plan of care is wrong, not the patient.

I think we sometimes use incorrectly use the definition of "plan of care" that medicine uses, which isn't a patient specific plan of care. It's that frequent failure of medicine to adjust for the individuality of patients that creates the need for patients to have nurses, which doesn't do much good if we're no different than medicine when it comes to this.

[iluvivt, BSN, RN]

Once you realize that patient's do have every right to refuse treatment it makes nursing a lot easier. It also tends to eliminate any game playing and attention seeking behaviors that patients may engage in. I often see nurses pleading with patients to have their IVs restarted and our team has told them again and again that it is considered battery to place an IV against the patient's wishes. I will explain and educate but I will not coerce or force. If they want to make me the bad guy I will remind them that he treatment is for their benefit and not mine. When their rights are respected they usually quit resisting and agree to the IV start.

Please do document all the teaching you have provided and the MD notification.

[luvababy5]

Education and documentation. Inform the PCP