Patient's right to have a decubitus ulcer ?

[Blackcat99]

I work in LTC and we have a few residents who become combative when you try to change them. I am curious as to what others do at their facilities. Do you allow them to refuse to be changed since that is their right to refuse? Or do you get 3-4 people and change the person anyway so they don't get decubitus ulcers? Thanks :)

[debbiemig]

Yes it's a difficult choice to make. Despite the fact that the resident was confused and physically assaultive to anyone who tried to change her and that charting was always documenting those facts still the family got that huge settlement. You're damned if you do and damned if you don't. If the skin breaks down you're the "bad guy." If you insist on cleaning up the resident to prevent skin breakdown you violate the "patient's rights" and then you're the bad guy for violating his rights. The other night there was a police car at my job and I was worried that maybe he was looking for me to arrest me for "assault."

This is a tough call! On one hand the resident does have rights, on the other, he is in the facility because he can't care for himself! If a resident is confused and clearly not able to make a rational decision, I think we have failed the resident if we don't turn and position, change them ect. They depend on the staff for these cares. We have an obligation to provide these cares. We may need to give choices as to time, perhaps it is as simple as they don't want to give up control. The choice may be something like " you are wet, I need to help you get cleaned up, I can do it now or I can come back in 1/2 hr. What would you prefer?"It doesn't always work, but sometimes it does! Skin breaks down very fast!

[CHATSDALE]

Had patient whose family complained when she was turned...woman was very large and would only lie on right side...i worrried about decub and pneumonia but don said to explain to fly and if they still insisted to go along with their wishes..of course i didn't know (and neither did don) just which member of her family was legally empowered to make decisions liike that...as others have said damned if you do and damned if you don't...

[Nursenan0]

I agree with the family involvement. We have an alzhiemers resident who would not take a bath or change clothes. We had tried everything from going back later to trying a different person to approach her. After getting the family involved we tried several different approaches with them. After identifying that the woman had always been modest and had had problems with having her clothes off we ended up doing a blanket bath with her....it doesnt always work but does a majority of the time. Family involvement might provide insight into the residnts reactions.

Nursenan

[lovingtheunloved, ASN, RN]

I work in a demetia facility. They are all combative. If we let them refuse everything, there would be nothing to do all day. They are there because they do not have the ability to make rational decisions. Their families have entrusted us with their care, because frankly, they beat up their family members half the time. There are different ways to approach things with different people. One resident I have will let you do anything if you rub her back with lotion afterward. Make the care their idea. Or come back later when they calm down. And sometimes, they will be non compliant regardless of your approach, and you have to do what is in their best interest, which in this case would be changing them. Many times they are combative because they are wet and uncomfortable.

[lovingtheunloved, ASN, RN]

I work in a demetia facility. They are all combative. If we let them refuse everything, there would be nothing to do all day. They are there because they do not have the ability to make rational decisions. Their families have entrusted us with their care, because frankly, they beat up their family members half the time. There are different ways to approach things with different people. One resident I have will let you do anything if you rub her back with lotion afterward. Make the care their idea. Or come back later when they calm down. And sometimes, they will be non compliant regardless of your approach, and you have to do what is in their best interest, which in this case would be changing them. Many times they are combative because they are wet and uncomfortable.

[veteranRN]

This is the way I see it. If the resident is alert and oriented then yes, they have the right to refuse to be turned. But I have the responsibility to inform them of the consequences of their decision. If they still refuse then it is documented.

If the resident is confused I would try to redirect, be creative in the way I get the resident to comply, involve the family/physician document all my attempts and even contact the ombudsman of the state for their assistance. Documentation is key. I guess in the end you could always transfer them to another facility if their combativeness is getting the way of giving proper care.