Refusal of Care

[*4!#6]

I am a new nurse. I want to run something by everyone to see how they feel about some difficult subject matter.

Recently I encountered a patient who is AAOx3, new admission, and doctor puts them on a fluid restriction. The patient is very confrontational and family is also involved. The patient and family are refusing the fluid restriction, and begin to argue, raise their voices, and make verbal attacks to staff.

I am wondering if my thoughts on handling this situation are correct. I would state to the patient that they have a choice in their care, and the decision to follow the doctor's recommendations is ultimately theirs alone. I would explain to them the reason for the restriction and possible consequences of not following the restriction. Then, if they still wished to refuse, I would document it in the chart and notify the MD.

Does this seem like reasonable course of action? The fact that the patient is acting like a two-year old throwing a tantrum, however this patient is not actually a two year old but a competent adult. I think that giving the patient the choice will make my life easier. On the other hand, I am worried about getting yelled at by the MD for "not educating the patient" or being in trouble if something goes wrong with the patient due to them not following doctor's recommendations.

[KelRN215, BSN, RN]

Competent adults have the right to make bad decisions and to not follow medical advice. All you can do is educate and document, document, document! I certainly wouldn't bring this man a pitcher of water if he's gone beyond his fluid restriction but if the family is sneaking in liters of soda or anything, what can you do?

Why is this person in the hospital if he doesn't want to heed the advice he is given though?

[Sun0408, ASN, RN]

Patients have the right to know the consequences of their actions. So yes, inform them of the reason for the fluid restriction etc, educate them on the effects of not following and document everything. Always let the MD know what is going on, they too can be helpful or DC the pt home if they are not wanting help. Of course this is for a competent person. I see nothing wrong with a little tough love and honesty. I us it often for my pts, not as a scare tactic but FYI. Yes, this is why we are doing this or this is why you need to do xyz to prevent abc.. Many become compliant once they have all the info. Of course I work ICU so med/surg is totally different with the frequent flyers.

I will not go against the order but if the family or pt is crafty, I can't stop them. They have a right to refuse the order, but that does not mean we have to "give" them what they want against medical advice.

[MunoRN, RN]

The only Nurse I've known personally to lose her license, lost it for this very reason. She had a bed-bound patient with a 1L fluid restriction ordered for CHF, the patient was A&O and was refusing the treatment, as is their right. The patient requested water, which he was not able to obtain himself, and the Nurse refused to get him any beyond his fluid restriction citing the order and the she had to follow the order. The patient filed a formal complaint and the BON pulled her license. When she left my Hospital she was also facing potential criminal charges of abuse of a dependent adult, rumor was that those charges were eventually dropped with plea bargain.

As a result of this incident we were required to review our review our patient refusal policies and review them with staff which also included a review of our fluid restriction policies. It was surprising how little evidence there is to support PO fluid restrictions in the case of HF. In multiple studies, patients had the same amount of time on IV lasix, same morbidity/mortality, and the same length of stay with or without a fluid restriction. Plus, patients on a PO fluid restriction actually had a much higher 30-day hospital re-admission rate (likely due to the fact that diuretics and ARB's were not titrated to the patient's actual PO intake). So in the end, this Nurse lost her license defending an MD order that really doesn't serve much purpose anyway.

[Sun0408, ASN, RN]

That sucks.. Im sure if you we did some digging, we would find nursing that were fired, lost their license because they went against the order and gave the pt what they wanted..

So we are screwed either way as usual. Damned if we do and damned if we don't.

[amoLucia]

'Damned when we do and damned when we don't'. Just said by the poster ahead of me. Thinking the same thing, weird!

[iluvivt, BSN, RN]

You as the nurse are legally required to honor the competent patient's decisions. A patient must be informed of the possible consequences of their decision and in some situations a patient may be asked to sign a document as a receipt of receiving the information and confirming the decision. As a nurse the MD needs to be notified of the patient's refusal and this should be carefully documented.

I have had many a nurse tell me the patient cannot refuse to have their IV placed and I tell them absolutely they can REFUSE..and have to give the nurse a little lesson in the law. I have often found that the patient is just upset,scared or anxious and when we give them some space they usually start requesting the IV or whatever they were refusing. Not always of course,but I find this often to be the case.

[evansmum]

I am a new grad, as well, and this was interesting to read...thank you to all of the responses. Naturally, I am petrified of making any decision that places my license at risk.

As everyone has said above, my first instinct is to do exactly what you said, OP. Educate, educate, educate...document, document, document. Call MD. CYOA.

[elkpark]

A competent adult has the right to refuse any offered treatment; as already noted, the appropriate nursing response is to make the physician aware and document, document, document. It is also the right of the facility to administratively discharge someone who is refusing the offered treatment (since it is a healthcare facility, not a hotel -- you are there to receive treatment, not just take up space and get waited on).

[CrunchRN, ADN, RN]

Tough situation and sounds like you are taking reasonable and prudent action.

[morte, LPN, LVN]

how can this happen? The order may not do much good, if any. But till it is proven, how can the board take a lic over this? I hate to say it, I am wondering if that nurse had more going on with the board than this one thing.

The only Nurse I've known personally to lose her license, lost it for this very reason. She had a bed-bound patient with a 1L fluid restriction ordered for CHF, the patient was A&O and was refusing the treatment, as is their right. The patient requested water, which he was not able to obtain himself, and the Nurse refused to get him any beyond his fluid restriction citing the order and the she had to follow the order. The patient filed a formal complaint and the BON pulled her license. When she left my Hospital she was also facing potential criminal charges of abuse of a dependent adult, rumor was that those charges were eventually dropped with plea bargain.

As a result of this incident we were required to review our review our patient refusal policies and review them with staff which also included a review of our fluid restriction policies. It was surprising how little evidence there is to support PO fluid restrictions in the case of HF. In multiple studies, patients had the same amount of time on IV lasix, same morbidity/mortality, and the same length of stay with or without a fluid restriction. Plus, patients on a PO fluid restriction actually had a much higher 30-day hospital re-admission rate (likely due to the fact that diuretics and ARB's were not titrated to the patient's actual PO intake). So in the end, this Nurse lost her license defending an MD order that really doesn't serve much purpose anyway.