Pts right to refuse treatment

rjflyn, ASN, RN · Apr 20, 2012

Kind of thin as far as suicidal goes. Though most doctors and facilities wouldnt let a patient whom has received narcotics leave that soon after receiving them though there are exceptions. Personally I know the kind, the providers I work with would let them go without a second thought, as we have too many patients who actually want to be taken care of. I myself also am not going to beg someone to stay, I just make sure they are making an informed, competent decision.

skylark, BSN, RN · Apr 20, 2012

I see a lot of sicklers in our ER, and usually they just want the pain managed and then they want to leave. No problem, i can understand the disease is a nuisance to them and they just want each episode treated asap so they can feel well enough to get on with their life. I can understand her comments about "tired of being sick", I hear that a lot.

I would not interpret that as suicidal, I would interpret it as someone fed up with spending hours in an ER because of a disease they did not ask for and which is inconvenient and painful. Most know what analgesia works for them, they just wants the meds sleep it off for a couple of hours and then go on their way.

Involving family and deciding someone is suicidal does not sound like the way to go. I wasn't there so I can't say much more but from what you say that sounds like a poor judgement to me : (

brainkandy87 · Apr 21, 2012

I bet a lawyer would love to meet this pt. I don't see how that's suicidal at all. It's simply someone frustrated with their disease and not feeling well.

VICEDRN, BSN, RN · Apr 21, 2012

The situation described is absolutely unacceptable! Unless your patient is intoxicated, under a psych holding order, has a cognitive problem like Alzhiemers or is a minor, she can not be forced into staying for treatment.I would've notified the charge, the team leader and house supervisor before restraining that patient.Further, her statements do not qualify as suicidal ideation as far as I have been able to tell from talking to other professionals.

nurse2033, MSN, RN · Apr 21, 2012

The PA is in a tough spot. If they let her go, even AMA, the patient could sue (maybe not win) anyway. Placing her on a hold creates a different type of liability, but at least this decision is probably safer for the patient. To answer your question, a patient who is alert and competent can refuse even if they will probably die. A friend of mine did an AMA refusal on a patient who was having an obvious MI with ST elevation. The patient later died but the refusal was airtight; the patient made the decision with all the facts.

However, a patient under the influence (ETOH, dilaudid) can be considered to be not competent until they sober up. The statement "tired of being sick, don't care anymore" is, to me, not suicidal ideation. That requires the active thought to want to kill yourself. Wanting to die and wanting to kill yourself are not same thing. I'm sure the team was playing it safe to keep the patient alive despite herself. It is just too bad that patients put us in these situations.

kids · Apr 21, 2012

I bet a lawyer would love to meet this pt. I don't see how that's suicidal at all. It's simply someone frustrated with their disease and not feeling well.

I was thinking exactly the same thing.

Calling the mother over the patient's objection is skirting a HIPAA violation also, did anyone bother to confirm if there was any truth to her claims? (I'm the mom of a guy who was combative postictal, he got hauled off to jail instead of treated because his EX wife, when called by EMS, denied he had any medical history. Fortunately he seized again within hours and was actually taken to the hospital where they had access to his records.)

The half life of IV dilaudid is around 2.5hours, I'm inclined to think she wasn't terribly impaired.

I think the PA was on a power trip, I hope they have good malpractice insurance and they keep it paid up. Would they invol a 22yo in ESRF refusing dialysis because they were " tired of being sick and didn’t care anymore.” Or a 21yo actively bleeding JW refusing blood products or a 25yo refusing treatment for a cancer with a good prognosis?

An unfortunate side effect of this experience may very well be that the patient will NOT seek help in the future.

Meriwhen, ASN, BSN, MSN, RN · Apr 23, 2012

From the psych nurse POV: a statement about being tired and not caring wouldn't be SI, or perhaps very vague SI. Is it enough to warrant a hold? I don't know: I wasn't there so I don't know exactly how the patient was and what went down.

But if her behavior was otherwise appropriate and if you consider her chronic condition that she can't escape and the fact she spent a long time in the ED, I would have considered it her being frustrated and not suicidal.

HOWEVER...

That being said, if there is any doubt as to whether the patient is serious about SI, it is better to treat it as though she were. But keep in mind that competent psych patients, even those on holds or involuntary committed, have a right to refuse treatment. It takes a separate court-ordered hearing (e.g. Riese) to force them to accept medications. It also takes another court hearing to declare them incompetent.

So they could have held her and she'd still be within her legal right to refuse treatment.

Larry77, RN · Apr 24, 2012

Let her go, flag her chart to the event and don't give her narcs next time. Some ED's do not treat sickle cell with narcotics, tons of fluids, check labs, if labs are bad then yes admit them with a PCA but big doses of narcs in the ED can be counterproductive and lead to scenarios like you experienced.

To hold someone against their will we have to be able to document a danger to ones self or others...just getting narcs does not IMHO meet this requirement.

That Guy, BSN, RN, EMT-B · Apr 24, 2012

Let her go. So what happens next time is she goes down in the field and dies. I might sound heartless but it happens. People get tired of fighting or want to die. Why must everyone live and get treatment?

hiddencatRN, BSN, RN · Apr 26, 2012

I wonder if the PA knew the patient well and had a more global sense of what was going on with the patient? The PA might have reason to be concerned about the patient being very sick in addition to being non-compliant/adherent/not wanting to participate in care.

That said...pretty weak justification for keeping the patient against her will. It's one thing to talk a patient in to staying (I'm usually in the "fine, go then" camp unless the kid is truly sick, and my situation is different because I work in peds so it's the parents who usually want to refuse treatment, and when the kid is super sick that's when we get social work and possibly child protection involved). In this case....I think the PA was overstepping.