No, you can't do that!

[LoveMyRNlife]

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.

[Davey Do]

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

This is sort of what happened with a recent case on our geriatric psych unit. The situation was a little different:

The patient had dementia, a hx of CVAs, was aphasic and wheelchair bound but was eventually treatment compliant and ready for discharge to home or a LTC facility. A family member was the patient's POA and refused to allow LTC facilities to have financial information for the admission process, but also refused to take the patient back home where they both resided.

The Dept. of Aging was eventually notified and there was a long meeting with a DOA agent, administration, social workers, and other staff before the family member agreed to take the patient back home.

And like LoveMyRNlife's family member, this family member was extremely difficult with which to deal.

A sad situation.

[NurseSpeedy, ADN, LPN, RN]

Give them some AMA paperwork and tell them if they're going to refuse all appropriate interventions for their condition, they may as well go home.

That's my fever dream response, because I know no place would actually let you do that. Too bad though.

We may not be able to respond this way, but I have had doctors at both nonprofit and for-profit hospitals do exactly that.

Of course the patients that they did this with were completely alert and oriented though.

[hppygr8ful, ASN, RN, EMT-I]

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 :)

I didn't get the sense that this was a psych patient but that the caregiver was demanding Haldol to keep the patient calm. This appeared to be a med/surge situation. Hospital legal department could get involved with social services consult to assess POA appropriateness but as a mandated reporter I would most like file an elder abuse case which would connect caregiver with services.

As a psych nurse myself I know Haldol is not an appropriate intervention for dementia related agitation. I also had a mother with dementia and severe aggitation and aggression who just happed to be allergic to both haldol and attivan. What these patients need is an appropriate and safe setting where they can be properly cared for. Once we found the right setting mom calmed down and was not on a ton of meds either, but such care is costly. In California where I live we paid $8,000.00 to $9,000.00 a month and it wasn't covered by Medicare either. Lucky for us my dad had set up a trust for my mom before he passed so we were able to pay for it.

Hppy

[LoveMyRNlife]

And yet another thread that could be put to music!

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.

I work for a not for profit hospital and a lot of times we keep these people forever, doing absolutely nothing for them but interventions they could be doing at home. I think the wonderful documenting done by all of the staff and strong boundaries helped to facilitate the discharge. It took 6 hours after the discharge order was written to get them out the door.

When you have people backed up in the ED needing a bed, and we have someone taking up a bed that refuses help, just very frustrating. Talking to the family member was like beating your head against a wall. That is when you leave the room repeating "I love my job, I love my job." Lol

[LoveMyRNlife]

I didn't get the sense that this was a psych patient but that the caregiver was demanding Haldol to keep the patient calm. This appeared to be a med/surge situation. Hospital legal department could get involved with social services consult to assess POA appropriateness but as a mandated reporter I would most like file an elder abuse case which would connect caregiver with services.

As a psych nurse myself I know Haldol is not an appropriate intervention for dementia related agitation. I also had a mother with dementia and severe aggitation and aggression who just happed to be allergic to both haldol and attivan. What these patients need is an appropriate and safe setting where they can be properly cared for. Once we found the right setting mom calmed down and was not on a ton of meds either, but such care is costly. In California where I live we paid $8,000.00 to $9,000.00 a month and it wasn't covered by Medicare either. Lucky for us my dad had set up a trust for my mom before he passed so we were able to pay for it.

Hppy

This was not a psych patient but an elderly patient with dementia that came in with AMS. When I tried to discuss the Beers list of medications that were counterproductive to what she was trying to accomplish, she yelled over me. This poor patient was on several meds on the Beers list. The admitting diagnosis said poly pharmacy yet she expected us to give haldol until "he went to sleep" She thought he just needed to rest.

[hppygr8ful, ASN, RN, EMT-I]

This was not a psych patient but an elderly patient with dementia that came in with AMS. When I tried to discuss the Beers list of medications that were counterproductive to what she was trying to accomplish, she yelled over me. This poor patient was on several meds on the Beers list. The admitting diagnosis said poly pharmacy yet she expected us to give haldol until "he went to sleep" She thought he just needed to rest.

The only time I have really seen Haldol used as a routine for a dementia patient is when they are end stage and it's being used for terminal agitation as part of their hospice orders. At that point we are not necessarily worried about cardiac effects but rather keeping the patient comfortable.

Hppy

[LoveMyRNlife]

The only time I have really seen Haldol used as a routine for a dementia patient is when they are end stage and it's being used for terminal agitation as part of their hospice orders. At that point we are not necessarily worried about cardiac effects but rather keeping the patient comfortable.

Hppy

Yes, I have also seen it used in Hospice care but this patient was not to that stage yet. I never really understood why the family member was so fixated on haldol. Since this person completely ignored the physicians and nurses, I can only guess it came from google or worked one time in the past.

For those that suggested the ethics committee or adult protective services, what was your experience with either one?

[turtlesRcool]

This was not a psych patient but an elderly patient with dementia that came in with AMS. When I tried to discuss the Beers list of medications that were counterproductive to what she was trying to accomplish, she yelled over me. This poor patient was on several meds on the Beers list. The admitting diagnosis said poly pharmacy yet she expected us to give haldol until "he went to sleep" She thought he just needed to rest.

Just because a patient or family member requests a certain medication, that doesn't mean a doctor has to prescribe it. That's kind of the whole point of prescriptions medications; only licensed practitioners can decide a patient gets that medication. Sometimes I'll call a doctor for more pain medication, and the doctor will point blank say, "she's not getting any more narcotics. Period." And that's that. If a medication is not prescribed, I cannot administer it. While I find it annoying when I think a patient legitimately needs something that a doctor won't prescribe (or doesn't address the problem the patient is having), it also gives me an 'out' with difficult family members - no amount of demanding or cajoling me is going to make a difference because I'm not the decision maker.

At that point I would simply remove myself from the equation. I'll explain why we're not giving a medication, but if a family member or patient becomes aggressive and starts shouting over me, that's when I leave the room. And call security, if necessary.

[TriciaJ, RN]

When I worked med-surg we had a nurse manager who hated getting sitters for confused people ($$$). She would actually browbeat the physicians into prescribing haldol and soft restraints. I worked psych prior to that job and knew haldol is really inappropriate for elderly confused people. That puts it in the category of "chemical restraint" which was actually against policy (if not illegal). And I never met a single confused person who couldn't Houdini their way out of soft restraints. It was a nightmare.

Trying to discuss the issue with higher-level managers of course got me nowhere.

[JKL33]

For those that suggested the ethics committee or adult protective services, what was your experience with either one?

I wouldn't say full-on ethics committee as much as basic care conference. In using that tool, it is routinely possible to facilitate more reasonable conversations because they are removed from the environment that has become chaotic, for number one. That is a huge benefit. Just this woman's screeching in the presence of the patient is making things worse for the patient, which reinforces her own rationales for the demands she is making ("Look at him, look how agitated he is! I want something done!")

If she can't/won't participate in a care conference, it should take place without her. She should know that her presence is desired and it is hoped that she will attend, but it will be held regardless if she chooses to attend. As far as what is happening at the bedside, in real time I would probably involve security. People don't have the "right" to severely disrupt and obstruct patient care by virtue of the fact that they are presently a decision-maker. She needs to understand clearly what needs to happen or the alternatives (and when I say what needs to happen, I don't mean not listening to her ideas about what the patient needs, I mean that she needs to know she is obstructing patient care and is not demonstrating decision-making capability and in that sort of a situation, here are the measures that we will take...)

Additionally if something is not going to happen she needs to be calmly and clearly informed of that. "We will not order additional haldol for reasons we have already discussed. It is not an option." Sometimes these difficulties go on and on because one clear message is not delivered early in the game. She isn't listening to the whys and wherefores. She needs to hear, NO, we must come up with a different plan, that one is off the table.

[KatieMI, BSN, MSN, RN]

Ethic committee is 1) cannot be gathered emergently, and 2) useless as it is. Ethics committee holds only "recommendation" power, an expert's opinion which can be followed or ignored according to any involved party's wishes.

APS, on the other hand, can wield real power. There have to be right circumstances for them - for example, APS cannot do anything for real about family who keeps 98 years old deeply demented LOL on torturous treatments and full code because "they still have hope" IF that "hope" is the only one thing in question. But in like 9 cases out of 10 I'd seen, there was something beyond hope - for example, an SSI check coming monthly, or inheritance battle, or manipulative religious nursing home administration who pocketed fees while convincing family that to let poor old dear go would be a mortal sin for which they all will be damned forever. In these cases, with a good presentation from SW and involved provider, APS can find something fishy in most cases. And "something fishy" from APS = very real trouble. So even a nudge toward that side frequently moves things back to reality.

[LoveMyRNlife]

When I worked med-surg we had a nurse manager who hated getting sitters for confused people ($$$). She would actually browbeat the physicians into prescribing haldol and soft restraints. I worked psych prior to that job and knew haldol is really inappropriate for elderly confused people. That puts it in the category of "chemical restraint" which was actually against policy (if not illegal). And I never met a single confused person who couldn't Houdini their way out of soft restraints. It was a nightmare.

Trying to discuss the issue with higher-level managers of course got me nowhere.

The nurse actually explained to the family member that it was a chemical restraint and we could not keep giving haldol until the patient went to sleep. The family member actually said they were ok with a chemical restraint but not the SOMA. SMH.