Patient with Dementia's Right to Refusal - page 2

Hello! I have a bit of an issue. There are certain patients I often take care of who have profound dementia--to the point of requiring hand-over-hand assistance for eating, unable to consistently... Read More

  1. by   HouTx
    It's situations like this that make me soooooo glad that my organization has established very strong Ethics Case Consultation committees in every one of our facilities. Members consist of clinical & non-clinical including at least one 'public' member - groups are facilitated by a chaplain or similarly qualified person. I have learned so much from these folks. Including the fact that just because someone is not 'competent' to exercise judgment about choice of chemotherapy vs. radiation, they certainly still have the capability of deciding if they want to be kept alive by artificial means - based on consideration of their life choices they have made over time to family members. I love our Ethics folks! Very committed to patient advocacy whenever legally possible.
  2. by   hunger4justice
    I know this is a late response, but it might help someone else. I am a retired lawyer now in nursing school. The answer to this is that the facility should encourage guardianship, sometimes called conservatorship, actions on the part of a responsible relative so they can then exercise the rights the now incapacitated patient no longer can. Thus, if the patient refuses, the trustee, or conservator, has the right to give legal permission to the treatment, action, etc. It is similar to a durable power of attorney, BUT only people with capacity to make decisions can execute a valid durable power of attorney, so those already incapacitated cannot, and that is why application to the court for guardianship is needed. I was just in a nursing home where they got the son to sign the durable power and then appoint himself as guardian...TOTALLY invalid. Most states also have provisions in the court for this process when there are no relatives. This does not address the problem of the patient saying you are trying to assassinate them, but legally, you can get the guardian to consent to care/meds, etc., so you can then do what is in the best interest of the patient without fear of violating their right of refusal.
  3. by   hunger4justice
    Battery only requires an unlawful touching, it does not require that you be injured. Please see my post on this thread as to the legal answer to the question (but doesn't resolve the combativeness of the patient who has advanced dementia...though sometimes talking them through can help with that...sometimes not). My post addresses legal issues and how the nurse and facility can do what needs to be done for the client and protect themselves as well.
  4. by   misstrinad
    There's a fine line of providing necessary care and right to refuse with dementia pts. I have worked with moderate to severe dementia pts in a lock down unit for 5+ yrs. About 12 out of 30 are incapable of feeding themselves at all if that gives you an idea. We have several that despite every trick in the book, psych intervention, meds, etc still scream, curse, and hit staff during any type of cares. We can't let them sit in bm forever or never get washed bc of their behaviors. That doesn't mean we don't attempt to continue trying to distract, console, comfort, convince, etc. With refusals document document document. Everything you and CNAs tried, what the res did/stated. Ask for advice from your manager/supervisor and find out exactly what they want you to do in these situations.

    With constant med refusals find out what the requirements are where you practice to be able to conceal meds or get a Jarvis order. We have several that get their meds concealed in insure, ice cream, or oatmeal. We had one once we had to hide crushed meds under the yolk in a cut hard boiled egg. We have another that gets her one psych med concealed in candy.

    I know dementia pts are never easy, it takes special patience to care for them. Best of luck!
  5. by   calivianya
    I really, really, really hate taking care of dementia patients for this reason. They are my least favorite patient population by a mile.

    My facility (hospital) allows dementia patients to refuse things. Had one a few months back refusing her labs. She was in renal failure and her potassium had been very high the day before. She refused lab when they came by. I tried to talk her into letting me draw blood but she refused me. The physician came by to talk to her and she still refused. She also thought we were all her relatives and she was at home... I wonder who exactly would have been sued if her potassium went so high that she had coded and died and we never drew labs on her. Would it be the phlebotomist? The physician? Me?

    They are just so scary to take care of. I could never work in LTC.
  6. by   sallyrnrrt
    my facility policy was every refusal, RP notified, doccumentation, and physician / provider notified, docummented, careplanned, and follow up on continued refusals.........
  7. by   zingyrocks
    Dementia nursing is full of a lot of grey areas, I used to work in a specialist unit that cared for those with neuro-cognitive disorders and I can fully understand the frustrations you have (esp. when families say "can't you just"). Dementia nursing is that area that isn't classed as mental health but you have most of the signs and symptoms that require some mental health support in order to protect both staff and patients. Where I used to work we used to have booklets called "All about me" from the Alzheimer's charity, something that would be filled out by friends or family so that we could learn more about the patient, what type of person they were... and could give us clues into what made them behave in certain manners (we used to have a patient who used to shuffle his hands every day at 5.30... turned out he used to work in a shop and 5.30 was when he used to count the days takings).With the medications, you can't force them to take them, but you can ask a mental health nurse practitioner to sign the paperwork for covert administration if it is deemed in their best interests (This was a god send and made things a lot easier). As for basic care provision you have to assess what is in the best interests of the patient and also what is safest for you (I personally almost lost teeth for trying to dress a skin tear wound, it wasn't worth it.) and clearly document your actions and attempts, pressure sores in some cases are unavoidable, due to nutrition, age, deterioration in health, so long as you have documented that you have done your best for this patient, thats all you can do.... you can't be accountable.

    Keep up the good care attitude, dementia nursing is so difficult! and I really respect anyone doing it
  8. by   nurseprnRN
    Interesting book: Learning to Speak Alzheimer's, by Joanne Koenig Coste (2003). Great resource for anyone who deals c Alzheimer's disease in any context, personal, professional, or social.
  9. by   elorne4647
    While I may be a relatively new nurse I have taken care of many patients with memory impairment as a unlicensed caregiver, CNA, nurse extern, and now an RN. From the sweet little grandma who flings four letter metaphors with fists of furry, to the less than appropriate ramblings of men with absolutely no filters. I've been hit, kicked, groped, and otherwise battered - and I have always respected my resident's right to refuse care in balance with their basic needs. I had a resident that screamed and swore and punched every single time we changed her. She was a big challenge for us as caregivers to meet her needs and not get pummeled in the process. Restraints, physical or chemical, are not the ideal route to go. Some people think they are the easiest. Having a multidisciplinary approach, getting to know your patients, and giving the individual the chance to make their voice heard while documenting, very specifically, every approach and redirect will not only help you and your healthcare team, but also CYA if something were to come up. If you can show the numerous, exhaustive steps taken to encourage compliance it will give you better ground to stand on than just saying, "Well we tried, over and over, we tried." With our patient mentioned above we found that distraction was the key, one CNA would hold her hands, gently, and talk to her about things she enjoyed and keep her distracted, while the other CNA performed cares. This enabled her to express her feelings, still get the cares she needed, and aside from a few well squeezed fingers, no CNAs were getting injured. From an RN standpoint I have a patient who routinely will refuse to take her oral medication. She may take her medications once a week at best. She may have no concept of what I am trying to give her, but she is not interested in taking them and in her state forcing the issue would not result in compliance. She may not understand what she is refusing, but she has the right, in my book at least, to tell me no. I make my attempt(s), and then document her refusal. The pills I am giving her aren't going to fix her, she isn't going to get better. If my forcing the issue is going to decrease her quality of life instead of increase it, is it right to force the issue? I don't think so and I know there are many out there who would disagree. When caring for a patient with a terminal diagnosis, which dementia is, quality of life over quantity. Will my insistence on cares/meds/treatment increase the patient's quality of life or just the quantity? Above all else keep the family on board and in the loop as well as management. Communication!
  10. by   Donnagg123
    What about a patient that has dementia and management is saying this person "has to" get up for day on night shift as therapy supposedly does this resident 1st when it is very obvious the person does not want up on night shift. Don't they still have a right to refuse?
    Last edit by Donnagg123 on Apr 1, '15
  11. by   dudette10
    Quote from Donnagg123
    What about a patient that has dementia and management is saying this person "has to" get up for day on night shift as therapy supposedly does this resident 1st when it is very obvious the person does not want up on night shift. Don't they still have a right to refuse?
    That is a care planning problem that needs to be addressed.
  12. by   EmergencyRN22
    I give great respect to those who care for patients with advanced dementia. Ideally, I only deal with such patients for a few hours. If we provide meds, usually they are IV/IM. In the ER, when we receive patients with advanced dementia they usually have family or close friends present. There presence are wonders. They keep pt entertained and normally in bed and not pulling on ivs or wires. They can help us identify physical, emotional, and changes in mental status. They influence greatly the demented patients cooperation level.

    Kinda off topic...

    Few shifts ago we had someone drop off their older relative to the Er lobby without coming in and seeing he gets registered and evaluated in the ER. The cutest older man, when approached he states he was there waiting for his plane to land because he was "going to see family in the old country". When asked, he denied every single complaint besides hunger and thirst. Asked him if he wanted to talk to a doctor - says no. I was able to get him to take me up on the offer of "free blood pressure and blood sugar check while he waited". Everything was WNL. Gave him a boxed lunch and juice and had him go back out to the lobby. I ended up getting our director involved and she called the pd. Then it was shift change, still unsure of his outcome.

    Hate to assume someone was trying to use us as an adult sitting service. I'm going to have to follow up with our director.
  13. by   tyvin
    In my area SNFs are for short stay patients (skilled beds). It sounds like yours is long term care with some skilled beds. Is it a facility that houses both?

    tewdles was right on with response.

    The one LTC place I worked, the first day on the job as charge I'm sitting at the nurses station and suddenly there are 4 CNAs literally dragging this women, who was screaming, to the shower. I stopped everyone and had them take the resident back to her room. Come to find out, the family was insisting that their mother be showered. So I told the CNAs to give her a bed bath prn (it's not like these people are out running a marathon). I called the daughters and had a meeting with them. I dug up lots of research on stuff that would get my message across and in the end the daughters agreed that it was not a positive thing to have their mother dragged to the shower against her will (only 1 daughter even knew they had to do that way). This had been going on for a year. Education people; remember, we are teachers as well.