Patients refusing assessments

[rkitty198, BSN, RN]

What do you do when:

Your patient refuses exams from you and their physician?

I cared for a patient who was septic due to shooting drugs into her femoral vein. She was in the stepdown unit for 9 days and was transferred to my floor (medical overflow). I heard in report that the patient had a "blister in her lady parts." per patient statement. I also was told that the patient was refusing for anyone to look at it or do a back assessment (Braden). I was also told that her MD's were baffled that she continued to be febrile despite the mess of antibiotics she was on.

During my morning assessment I asked the patient about the "blister." She said that it was "better," and refused an assessment of the area and her back. I also asked if she wanted to walk and she refused. I told her about the risks associated with not ambulating and she said "I know, that is why I do leg exercises in bed." At the time I let it go and asked the CNA to not assist her getting up without me being there so I can do my assessment.

Later in the day she needed the bedpan (she has refused to walk for over 10 days and insisted on the bedpan). The sheet accidentaly fell and as I was handing it up to her I saw this "blister."

The labia was so big that it was hanging between her legs like testicles! No wonder why the poor girl didn't want to walk! I also was able to get her to turn to her side when removing the bedpan. I saw stage II's on her coccyx and buttocks. I was horrified.

I called the MD and she said "I heard about this blister, but she never let anyone examine it." Not even the MD's saw this "blister," but knew about it?! I could not believe that just because a patient tells us not to assess something, we listen! This "blister," could the be the reason as to why she wasn't getting any better- and if you all had seen this thing you would agree! I wonder if anyone even assessed the femoral area for abcesses?

I went back to the nursing documentation and half of the assessments note that she refused the assessment and the other half documented her skin to be intact (it may have been at that time, but how would anyone know if she refuses the assessments?). Physician assessments also document refusal of assessments.

What is your practice if a patient refuses care? Do you just document the refusal? Do you get creative in ways of assessing patients? Do you feel it is okay to not assess patients because they refuse?

To add more, this patient refused CT scans, X-rays and other diagnostic care. One would think that if she refused these other diagnostic tools, a physical assessment by an MD would be imperative.

[psu_213, BSN, RN]

The labia was so big that it was hanging between her legs like testicles!

I really could have lived without having to read that.

Chart, chart, chart....a pt can basically refuse anything. Make sure you chart on it....

Also, you could ask her if she would be more comfortable if some else assess it, ask her what makes her uncomfortable about it, etc...in the end, it's her choice if you get to look at it. If she digs her heels in, there is not much you can do.

[Whispera, MSN, RN]

Since she's refusing assessments and diagnostic tests, what is her care based on, besides femoral vein-originating sepsis? What is she there for if she won't allow assessment? Four hots and a cot? I bet people are thinking that.

I would think someone would be thinking it's time for her to be discharged if she isn't willing to do what needs to be done.

Ok, I've vented...now to think in a caring manner...this is a really sad situation, and her future is kind of obvious. She's hiding something, I think. She doesn't want anyone to see things. I'd be thinking about that and trying to get past her refusal to the reason for it. Was she raped and doesn't want her blistered area touched due to rape-trauma? I know we can only do so much in the few days patients are with us, but this woman has gone through something intense.

Patients do have the right to refuse care, and we document the refusal. At some point, though, we need to figure out why they refuse, and help them past it, or what's the point of them being hospitalized? They come to us and we do the best we can...

[highlandlass1592, BSN, RN]

It's truly a difficult situation. If the patient is truly avoiding care, then maybe they should just be discharged. For some patients, it's a matter of embarrassment or even a lack of education regarding the current plan of care.

But ultimately, patients do have the right to refuse care from anyone. The core of the issue is thorough documentation regarding the incident, attempts at re-educating the patinet regarding the need for care and then the patient's response to the re-education. What can be hard for any healthcare provider to remember is that all patients have the right to make bad decisions.

[rkitty198, BSN, RN]

Patients do have the right to refuse care, and we document the refusal. At some point, though, we need to figure out why they refuse, and help them past it, or what's the point of them being hospitalized? They come to us and we do the best we can...

If I could hit the kudos button a million times I would. That is exactly how I feel.

Pneumonia was the admit reason.

[Mrs. SnowStormRN, RN]

First thing I thought was "How old is she?" and has she been raped. This may be the issue. Im sure someone has said "we cant give you the care you need if we cant do an assessment on you." If you cant assess, it will be difficult to treat and she may as well be discharged. Hope she gets comfortable soon so that she can be treated Just continue to do your documentation and mention how many times you offered and that you told her the purpose/importance of assessment. GOOD LUCK!

[hannahmaepunk]

We can't force them if patients refuse care.

We just have to have them sign the consent and state the reason. We nurses automatically explore the client's feelings and reiterate the risks of refusing the said type of assessment and care. We are not like the ones in "House,MD" show who manipulates patients and/or barge into their house to get more information.

[LegzRN]

I'm just really surprised she went for the femoral vein, but then a quick search yielded that it isn't all that uncommon. I've seen arms, hands, fingers, lower extrem, feet, ankles, and toes, but never the femoral vein. Crazy!

[nurse2B444]

A lot of people are mentioning that she should just be discharged if she is refusing care. While that is a very valid point, it doesn't sound as though she is refusing all care, because she is being treated with antibiotics, right? If she is able to have benefit from this treatment, she should be able to remain in the hospital. However, this raises the issue of liabilities because if she is remaining in the hospital and developing ulcers because she won't move or turn, does simply documenting the refusals cover the RN/hospitals ass enough? This is a tricky situation. Maybe a psych consult would be appropriate?

[Vanillanut, DNP, RN, APRN]

A huge part of nursing is exposing your patient, and to me it sounds like this was missed. Patients can be talked in to assessments, although they might not exactly enjoy it. I've had patients initially refuse but once spoken to they reluctantly concede.

I hope you are getting that I'm not approaching the patient in a nice, sweet, "please miss patient may I" nice tone. I'm somewhat direct/honest by nature and don't hold back much. Often I will be able to get patients to cooperate even if they don't like me at the end of the day. What's more important, that they like me or they survive? And 99% of the time they turn around later and like me, and respect me, and ultimately trust me more for looking out for their best interest.

I'm not hanging the OP out to dry, because obviously a lot of other people were involved with her care- it just seemed that perhaps an attempt to examine her appropriately wasn't really done all that great.

[Batman25]

Sounds like she has a massive drug prob so she still might not be totally in the right frame of mind. Does she seem embarassed when you ask about the blister? Does she flinch during exams? Could be an abuse issue but I'm not getting that vibe. Is she homeless? If she is she could just be holding out thinking the worse she gets the longer she has a bed. Sad and insane as that seems it could be true. She could also be looking for a lawsuit and a payday. You just don't know these days.

I would try talking to her as openly as you can and just lay out the facts. Ask her why she is refusing if you haven't already. If she brings up fear or embarassment you can tell her you understand, offer to hold her hand, have a friend in the room, etc. Failing that has she had a psych consult yet? I might go that route.

Patient does have the right to refuse but you still can't document enough here. Everyone needs to document and document more.

[LegzRN]

If she's not budging you need to work your way up your chain of command letting everyone know about this problem so no one can say "why wasn't I informed of this?" I mean, charge RN, unit director, nursing supervisor, hell, even the CNO. She's not progressing and she's costing the health care system $$$$$$$. Screw this patient autonomy crap, at a certain point it's either our way or the highway. I don't mean to sound like a cruel inhumane person, but it just has to end at some point.

By all means, try and get this woman the help she needs as therapeutically as possible, but if that fails, you need to explore other options.