Hello! I have not visited this forum in awhile, and I have missed it!
I live in Canada, and have a ethical dilemma/question:
I work for an assertive community treatment team (outpatient/community psychiatry). We currently have a patient who has not been medicated for 2 years (as they refuse any and all medication), and has gradually worsened since then; However, at this point, is still considered capable to make treatment decisions.
My dilemma is this: One of the social worker's on the team approached me and asked how I would feel giving our patient money in exchange for allowing me to give them an antipsychotic injection. I told her that I felt it was unethical to essentially bribe a patient to take an injection, and that I would not feel comfortable participating in this.
Well, she consulted with our psychiatrist and our psych resident and our resident went out with the social worker and gave this patient $20 in exchange for receiving the IM (typically it is only nurses who give IM's on the team, we are just lucky to have a resident right now who is very hands-on!).
So now I feel I have been forced into this difficult situation where I do not feel comfortable bribing our patients, but this patient's IM has been restarted and the only way they would accept it is by me giving them $ (which, I should mention, this patient will end up spending on crack).
My question is: Can anyone link me to some standard of practice, or nursing regulation that will help support my standpoint when I am sure to get blow back from my co-ordinator/other team members? I couldn't find anything in the CNO standards, and would appreciate some guidance!
I'm getting a blank page on page 8 of the Code of Ethics on your link. What concerns about the OP's scenario do you think are addressed by the ANA Code of Ethics?
I will just add that, had the RN done this (pay the client to take the shot) independently, autonomously, without discussing this with the rest of the treatment team, I would have significant concerns about the situation. But this is an intervention that was decided on and endorsed by the rest of the treatment team. I agree that, if the OP is uncomfortable with the situation, she should address her/his concerns with the rest of the treatment team. However, it is also true that there is a sizeable body of literature available on the ethics and efficacy of the use of incentives in healthcare.
(And are you really unsure about whether getting paid for our work is a violation of our autonomy? :))
I am talking about the patient's autonomy not RN practice autonomy. the patient's right to make decisions for themselves and have those decisions respected by the hospital staff and providers. I actually sent the OP's post to one of my professors from last semester that taught the theory/ethics class. I will let you know if I get her perspective on it. I think this is an interesting topic and I am definitely not claiming any expertise on the subject, rather I was posing question about where ethical dilemmas may lie based on what I have been taught thus far...
This is the most interesting thread I've ever seen on Allnurses.
I think what we are missing in the conversation, is that the OP says that she is almost certain that the patient would spend the money on crack. Given that, there is another ethical layer to the story.
I suppose that problem could be bypassed if the patient was agreeable to a different type of incentive. But if he isn't, then there's little difference between saying "You can have 20 bucks if you take your injection" and "You can smoke crack if you take your injection."
Still not sure whether or not incentives are ethical even without the crack problem, but I think it's a pressing issue in this particular case.
Good Point! I agree with this being a very thought provoking topic, Would be wonderful if the OP contacted their BON and let us know what their thoughts were on it. Like many ethics questions, there is often no black or white answer. What the BON says would be my gospel on the subject as they are the ones who will control my license. Doesn't mean I would have to agree with it, but would mean I am protected legally if I followed their advisement on it.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
I was an ACT nurse very recently in my career. I, too, had a patient who clearly needed to be medicated due to psychotic symptoms but was with capacity in terms of decision-making. What we did was slightly different. She had been bugging her case manager to take her shopping for sneakers (the patient had the money but we were her payee and needed to approve any special request checks out of her account) so her case manager said, "well, I'll take you into the office, the nurse will give you your shot, then we'll go get your sneakers." It was the only way she would accept the shot. We were bribing? Yes, but it was with her own money.
In your case, I would tell the resident that he or she had to finish what was started, and that you are not on board with this at all. If the injection begins to work after a few doses, the patient may very well come around and realize the improvement in quality of life.
ACT is not for those who can't think outside of the box.
Bribed a patient with her own money? She couldn't use her own money to buy the sneakers that she wanted until she agreed to accept medication? That's an ethics question in itself.
"This patient will just end up spending it on crack", well I guess there's the issue of a psych patient using crack cocaine vs. a psych patient going unmedicated? I definitely don't have any solid answers because I'm very unfamiliar with what you do, but this is a very interesting discussion.
The question is whether or not it is all right to offer $20 as incentive, not whether or not the patient is able to make treatment decisions.
Nurses coerce patients all the time already with the false "if you leave AMA, insurance won't pay for the stay BS" If it works, the patient gets medicated, and the patient is willingly participating, I'm not sure that there would be an ethical issue.
The clients for whom we were payee had at one point been deemed without capacity to make financial decisions on their own behalf (as decreed by a psychiatrist and approved legally) or decided that they needed our assistance and signed over their financial rights. Although our clientele mostly was with capacity during my tenure, we remained their respective payee. This meant that their benefit payout went to us, not them. I think any additional income went to them (not many worked).
Being their payee included a budget, which was approved by a case manager, psychiatrist and the client. Weekly checks were handed out based on said budget and special requests were also possible. However, there were stipulations within the special check request. Receipts must be turned in, the nature of the request must be in writing prior to the check being cut, and money must be available that also allowed for the aforementioned budget to continue.
This particular client never gave us receipts and was in danger of losing her special request privilege (a privilege she had agreed to). So this was, in fact, a special privilege that the case manager had to have okay'd by finance. It's not much difference than an advance on allowance or dipping into savings that weren't previously agreed upon for that purpose.
As their appointed financial power of attorney it's not legal to withhold their funds unless they do something for you, this is actually felony extortion despite the legal right to manage their funds. A financial POA can only ensure that the person is spending their money appropriately, and shoes would be an appropriate purchase, 300 pairs that aren't even their size would not be.
Specializes in Medsurg/ICU, Mental Health, Home Health.
As their appointed financial power of attorney it's not legal to withhold their funds unless they do something for you, this is actually felony extortion despite the legal right to manage their funds. A financial POA can only ensure that the person is spending their money appropriately, and shoes would be an appropriate purchase, 300 pairs that aren't even their size would not be.
You know what, I didn't work in the financial department. But there was a stipulation agreed upon regarding special request checks. If said checks were requested, receipts must be provided or further requests could be denied.
Also, this isn't a POA situation. My agency was her payee, meaning her benefit checks were made to the agency, not to her. So legally the money was ours. We just didn't spend it. It stayed in the bank unless otherwise stipulated in the budget (i.e. weekly checks and special requests as deemed appropriate). Furthermore, the clients could, as long as they were no longer considered without capacity, become their own payees again or appoint someone else as such. Sorry I didn't explain that further. I didn't even know what a payee was vs. something like the financial POA my mom had with my grandmother until I worked ACT. Sorry if that doesn't make sense.
Also, she wasn't "doing something for us," we were attempted to think outside of the box to keep her out of the hospital, or in her case, jail. This was another individual who would spend her money on booze and crack with the special request checks vs. what they were intended for. It didn't make one difference to us if she accepted the shot - it was for her well-being.
So I suppose I spoke out of turn concerning saying we were bribing her with her own money. It was legally the agency's money. However, the money was to be used for her alone, and it was. We just had to try our darnedest to keep her safe. Can't commit a psychotic person who doesn't meet dangerousness criteria, now.
Specializes in Medsurg/ICU, Mental Health, Home Health.
Bribed a patient with her own money? She couldn't use her own money to buy the sneakers that she wanted until she agreed to accept medication? That's an ethics question in itself.
Please read my other responses about this, the above one and the others. This isn't as cut and dry as it sounds.
We had to bend over backwards to get finance to approve the request in the first place because she'd pretty much lost her request privileges and had essentially bled her finances dry.
The reason why I emphasized that it wasn't any staff member's money is that doing that was considered by every mental health agency I know to be a conflict of interest. It was showing favoritism and the concern was that, like a PP stated, that it would be one of those "She told two friends, and she told two friends..." situations.
How about demands money for not becoming violent or killing someone or abducting someone? When you begin applying logic to psychotic sxs as is the case here then the lunatics have taken over the asylum. Priority is medication to relieve sxs which will hopefully increase insight and allow for ongoing TX. If said PT remains unmedicated commits a violent crime then the implications might mean convictions, removal of license and worse a sullied reputation so little possibility of further work. This sounds like a matter for the court and a judge's order meanwhile I would write copious notes with the sole intention of CYB!
You could also research the UK's Sections 135 and 136 which has all the information you would need to resolve this situation legally, ethically and professionally.
Specializes in Medsurg/ICU, Mental Health, Home Health.
How about demands money for not becoming violent or killing someone or abducting someone? When you begin applying logic to psychotic sxs as is the case here then the lunatics have taken over the asylum. Priority is medication to relieve sxs which will hopefully increase insight and allow for ongoing TX. If said PT remains unmedicated commits a violent crime then the implications might mean convictions, removal of license and worse a sullied reputation so little possibility of further work. This sounds like a matter for the court and a judge's order meanwhile I would write copious notes with the sole intention of CYB!
You could also research the UK's Sections 135 and 136 which has all the information you would need to resolve this situation legally, ethically and professionally.
That would be the "dangerousness criteria" I mentioned. Those threats = ability to be committed, or if deemed with capacity, arrested.
Why would an unmedicated patient committing a violent crime result in any action against the staff?
Also, every ACT team member here is in the US or CA so UK's laws wouldn't be terribly helpful.
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SouthpawRN
337 Posts
I am talking about the patient's autonomy not RN practice autonomy. the patient's right to make decisions for themselves and have those decisions respected by the hospital staff and providers. I actually sent the OP's post to one of my professors from last semester that taught the theory/ethics class. I will let you know if I get her perspective on it. I think this is an interesting topic and I am definitely not claiming any expertise on the subject, rather I was posing question about where ethical dilemmas may lie based on what I have been taught thus far...