No, you can't do that!

Nurses General Nursing

Published

I am just curious how other facilities handle patients and their family members that refuse most of the care while in the hospital. I am referring to declining the use of the gait belt, refusing IV fluids, refusing vitals, refusing lab draws, but demanding specific medications. I am guessing the answers may be different for nonprofit and for profit hospitals so please share that in your answer as well.

Does not matter if the facility is for profit or not. Is the patient competent? If not, the family member trying to call the shots.. must have a Durable Medical Power of Attorney.

Either way, document precisely and make sure the physician is informed of these wishes. I would not withhold any treatment or give any medications without the physician's order to do so.

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Specializes in Travel, Home Health, Med-Surg.
This patient would not be safe to leave AMA. If they are alert and oriented and they refuse treatment, that is their right. Unfortunately the patient was suffering because of the family member. Thankfully the patient was discharged to a long term care facility where hopefully they can get the help they deserve.

Yes, I didn't mean the patient in this case, but the family who I guess had POA. If the family has POA they can take the patient AMA unless it would be a danger (no family to assist at home etc) then you would need to get social worker involved. Yes, these situations are very frustrating!

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Specializes in ICU, LTACH, Internal Medicine.
"Patient/caregiver refused ordered treatment. Education provided on the benefits of treatment and risk's of refusing ordered treatment including discomfort, permanent disability or death and all parties present verbalized understanding. Physician informed."

Hppy

"Was called by RN d/t situation. Please see nursing note above. Attempted education about ... and scientific explanation of... . Family/patient are not receptive to education, raising voices, demanded inappropriate treatments/controlled substances administration. Escalated situation despite of the writer's best efforts to explain clinical situation to the patient/family. The writer had to call RN in room and the RN Hppyr8ful proceeded to call security in the room. Family was asked to leave and did so with security officer Joe Doe. Labs reviewed, stable (details). Vitals reviewed, stable (more details). Patient at the present time has no s/s of immetiate life threatening conditions. Can be safely discharged any time to SNF pending STAT Case Management consult and crisis team intervention, both instances notified by the writer.

Service will sign off. Please see discharge summary."

KatieMI, FNP-C, Hospital Internal Medicine. Date/time.

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Specializes in Psych ICU, addictions.

Depends. One or even a few days of refusing is not going to result in us showing them the door. But...

If they were admitted voluntarily and keep refusing: usually discharge, sometimes AMA.

If they were admitted on a hold: more than likely they end up going onto an even longer hold. Then they get a hold hearing. If they win the hearing, they'll usually ask to leave and most likely will be discharged AMA. If they lose the hold hearing and they keep refusing, then comes a Riese hearing. If they lose the Riese hearing, they can no longer refuse the psychiatric portion of their care (they can still refuse medical treatment). If they win their Riese hearing, they usually end up asking to discharge or being discharge because what's the point in holding them any longer if they're not taking their psych meds?

All discharges pending assessment and clearance by MD, of course.

Remember that in psych, it's a whole different ballgame :)

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.

If the family member is POA and refusing appropriate care for the patient, is it worthwhile/doable to get Adult Protective Services involved?

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If the family member is POA and refusing appropriate care for the patient, is it worthwhile/doable to get Adult Protective Services involved?

If the patient wasn't discharged then that would have been the next step. There was a very strange dynamic there.

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"Was called by RN d/t situation. Please see nursing note above. Attempted education about ... and scientific explanation of... . Family/patient are not receptive to education, raising voices, demanded inappropriate treatments/controlled substances administration. Escalated situation despite of the writer's best efforts to explain clinical situation to the patient/family. The writer had to call RN in room and the RN Hppyr8ful proceeded to call security in the room. Family was asked to leave and did so with security officer Joe Doe. Labs reviewed, stable (details). Vitals reviewed, stable (more details). Patient at the present time has no s/s of immetiate life threatening conditions. Can be safely discharged any time to SNF pending STAT Case Management consult and crisis team intervention, both instances notified by the writer.

Service will sign off. Please see discharge summary."

KatieMI, FNP-C, Hospital Internal Medicine. Date/time.

Everyone involved charted thoroughly about the situation and actually we did have to tell the family member, after she called a nurse a ******* *****, that if she did not stop yelling at the nurse's station that security would be called.

Transportation showed up to take the patient the ECF, and had to wait 20 minutes for this person to yell at another physician and supervisor because she was refusing to allow the patient to be discharged. Needless to say she did not get her way and the patient was discharged.

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Specializes in Med Surg.

I ask them why they are refusing or objecting. I consider the patient's goals, the reasons for the objection, and which of their requests I can grant and those I will not. I try to calmly explain what I am going to do or not do in response to their requests

In some cases (specifically cases where the patient or my job is in danger) I will call the attending (or security if needed) to come help explain why I will not grant their request.

These patients invariably end up firing me and quite easily finding another nurse they can push around at will.

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I ask them why they are refusing or objecting. I consider the patient's goals, the reasons for the objection, and which of their requests I can grant and those I will not. I try to calmly explain what I am going to do or not do in response to their requests

In some cases (specifically cases where the patient or my job is in danger) I will call the attending (or security if needed) to come help explain why I will not grant their request.

These patients invariably end up firing me and quite easily finding another nurse they can push around at will.

We did ask the family member why they were refusing and basically the answer was the family member knows them better. The gaitbelt is constricting and will agitate the patient. As far as medications, the family member kept asking for haldol to "make the patient go to sleep" but not "snowed" Basically it really seemed to be about the family member. Every person spoke in a calm voice when dealing with the family member and explained the reasons why the plan of care was best for the patient. The family member continued to request haldol after it was explained to them that it prolongs the QT interval and telemetry is needed. The family member still refused telemetry, vitals, and any form of education.

Very frustrating for the staff because we genuinely wanted to help the patient.

The staff did set good boundaries with this family member so I am sure that was part of their heightened response to everything that went against what they wanted.

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Specializes in SICU, trauma, neuro.

Refusal of medical plan of care, despite education: have the MD come and talk to her.

Refusal of safety measures: neither pt nor family has the right to refuse. No gait belt, no walk. Sick of hearing about staff safety? Too bad. It's not negotiable.

In my world (critical care).... or really in any world: if family is obstructing needed care, security sees them out. Of course if it's a situation where the POA is wanting heroic measures stopped, that is different ... but if they are demanding "Save his life... but no he can't have levophed" and physically preventing me from hanging levo? Nope.

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Specializes in Psych (25 years), Medical (15 years).

And yet another thread that could be put to music!

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At Wrongway Regional Medical Center, a for-profit facility, there is no consistency when dealing with non-treatment compliant patients.

Everything's been done with non-treatment compliant patients from discharging them to the street in their wheelchair to keeping them forever to buying them a plane ticket to California.

I'm not kidding.

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Document it all.

Does your hospital have an ethics team you can call?

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