I currently work in home care for quadriplegics who require trach and vent care.
I have a client who I love dearly, but is extremely noncompliant. He refuses ROM, ADLs, he has refused to get in his wheelchair for the last two years, ect ect
Most recently he refused his Miralax (the only bowel medication he is on) for 2 weeks and ended up with a fecal impaction which he refused to go to the hospital for treatment.
My manager is completely uninvolved. She is intimated by him and doesn't want to emphasize things he doesn't want to hear.
What at is my responsibility here? I know he has the right to refuse, but it seems extremely unethical to allow someone so much say over their care when they aren't in the medical profession and don't understand how serious the situations are.
Please help, I'm worried I'll have to come off this case that I love. Simply because I can't stand around and watch him die.
Perfect advice. Document. As a hospice nurse, I see patients who make choices I would not make for myself all of the time. Some separation from your patient might actually be a good idea for you. Perhaps work on another case for a while? Regardless, good luck to you and thanks for the post.
Thanks so much for your post, it helped a lot! I've considered what you said and decided to try another case.
I'm so sad and suprised by how many negative and scarcastic comments this post got. I asked for help and advice from veteran nurses, and I was mocked.
This patient declines total care from our nursing staff. He gets no oral care, no bed baths, no hair washes, he lays in soiled sheets and shirts for days, no range of motion, he is on a ventilator and gets no cough assist, no chest percussion, no nebulizer treatments, he refuses all bowel medications leading him to go 7-12 days before evacuating (unless he gets a bowel obstruction and then refuses enema/suppository/ER), he will not allow to be turned, he has pressure ulcers that he does not want dressed that are now tunneling. I could go on and on and on and on.
Does he have a right to refuse treatment? Absolutely. Do I have to participate in his death by refusal? Absolutely not.
The doctor I work with put it perfectly, "it puts you in a tough spot, because your job is keeping him alive but he's refusing anything that will"
I never implied that I wanted to "chain him the the bed" to preform care. I actually said that I was thinking about leaving this case.
As for getting too close to this case, yes I'm sure I did get too close. It's very hard not to when you work 40-50 hours a week with someone for 3 years in their own home. That's not a crime, simply a reason to change cases. Which was politely suggested by some, and I'm very grateful for this.
In the end, I documented my little heart out. And I put in for a transfer. I still care for my patient, nothing can change that. But now I'll do it from visiting and phone calls.
Thank you very much for everyone who took time to answer my question!
Yes, I believe he wants to die but will not go on palliative care because it's against his wife's wishes. It's a very sad situation. He was a person who had a lot of control over his family and business and now has no control. Thank you very much for your comments! :)
I'm so sad and suprised by how many negative and scarcastic comments this post got. I asked for help and advice from veteran nurses, and I was mocked.
AbigailJo,
I suspect that you might have been referring to me. I was not mocking you but attempting to stimulate critical thinking on your part so that you might arrive at a conclusion yourself. I was using a teaching method similar to the Socratic Method.
First I must congratulate you on your concern and compassion for the patient. No to explain my position...
You originally stated:
I know he has the right to refuse, but it seems extremely unethical to allow someone so much say over their care when they aren't in the medical profession and don't understand how serious the situations are.
Let me show why this does not work. This line of thought was the basis of the eugenics movement, which started in the US in the 1800s and spread to Europe. The most extreme example was the Nazi death camps. This line of thinking was the same as the example you describe (someone deciding the direction of another's life) except the reverse is prescribed (you advocate more care, the death camps prescribed ending life).
While eugenics focuses on purifying certain groups, some of the accompanying policies and methods of practice involve ignoring the autonomy of the individual. One way this is done is through the forced sterilization of disabled people. This practice occurred in the United States up through the 1970s.
Slavery was partially justified (source: The Smithsonian) by the thought that slaves were incapable of making intelligent choices in their own lives. The right to die movement (which gave us POSTs and DNR) was based on the right of the individual to choose the course of their own life. (Note: the right to die is actually the right to die with dignity.â€)
All this is based on the God given right of free will which lead to the right to autonomy. Perhaps the best explanation resides in the United Nation's The Universal Declaration of Human Rights (which was a direct result of the Holocaust).
Perhaps, after reading this you can convey an understanding of your patient's perspective and maybe even convince your patient to allow care.
Perhaps someone disregarded his right to autonomy and personal choice, and that caused him to refuse all care. Many people who have had their dignity disregarded opt out†of healthcare and would rather suffer the effects of disease than be subjected to undignified treatment. That is the whole basis of the right to die with dignity.â€
Specializes in LTC,Hospice/palliative care,acute care.
I still care for my patient, nothing can change that. But now I'll do it from visiting and phone calls.
Thank you very much for everyone who took time to answer my question!
I get that you care about this patient but you need to learn healthy boundaries.Transferring to another case is the appropriate action but following up with visits and phone calls when you are off the case is really not appropriate.
I suspect that you might have been referring to me. I was not mocking you but attempting to stimulate critical thinking on your part so that you might arrive at a conclusion yourself. I was using a teaching method similar to the Socratic Method.
First I must congratulate you on your concern and compassion for the patient. No to explain my position...
You originally stated:
Let me show why this does not work. This line of thought was the basis of the eugenics movement, which started in the US in the 1800s and spread to Europe. The most extreme example was the Nazi death camps. This line of thinking was the same as the example you describe (someone deciding the direction of another's life) except the reverse is prescribed (you advocate more care, the death camps prescribed ending life).
While eugenics focuses on purifying certain groups, some of the accompanying policies and methods of practice involve ignoring the autonomy of the individual. One way this is done is through the forced sterilization of disabled people. This practice occurred in the United States up through the 1970s.
Slavery was partially justified (source: The Smithsonian) by the thought that slaves were incapable of making intelligent choices in their own lives. The right to die movement (which gave us POSTs and DNR) was based on the right of the individual to choose the course of their own life. (Note: the right to die is actually the right to die with dignity.â€)
All this is based on the God given right of free will which lead to the right to autonomy. Perhaps the best explanation resides in the United Nation's The Universal Declaration of Human Rights (which was a direct result of the Holocaust).
Perhaps, after reading this you can convey an understanding of your patient's perspective and maybe even convince your patient to allow care.
Perhaps someone disregarded his right to autonomy and personal choice, and that caused him to refuse all care. Many people who have had their dignity disregarded opt out†of healthcare and would rather suffer the effects of disease than be subjected to undignified treatment. That is the whole basis of the right to die with dignity.â€
Oh, good lord. You weren't stimulating critical thinking...you were being an *******.
Oh, good lord. You weren't stimulating critical thinking...you were being an *******.
And now, you're being needlessly pedantic.
BTW, the conversation ended two months ago...
I would rather say my peace 2 months late than leave something un said. No regrets.
If you ever participated in philosophic debate, it is all about the pedanticalness and formalities. The Socratic Method involves questioning, and is probably the most popular method of debate. A form†of the Socratic Method is a style called the Devil's advocate.â€
The narrative style of the Devil's advocate style of debate (as opposed to the inquisitive style), is parody. The most famous historical parody is Jonathan Swift's A Modest Proposal.â€
The line of thinking that one decides what is best for everyone else is extremely dangerous. The risk warranted such a response.
You cannot force a patient to do anything even if he ends up harming himself in the process. As others have said, keep documenting, but also keep offering whatever it is with explanation. Patients who are bed bound with trach and vent often take years to come to terms with their limitations and express that anger through noncompliance. I've had a couple of those, and eventually they get tired of the harm they do themselves and start not only complying, but requesting the care you've been offering. Trust me. Oh, and there's really nothing management can do except at their quarterly recertification visits, reinforce everything you are offering and informing them about. Seriously.
AbigailJo
42 Posts
Thanks so much for your post, it helped a lot! I've considered what you said and decided to try another case.