? regarding Non-stated mandated residental resident

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Specializes in OB, ortho/neuro, home care, office.

Hi all

I have a question. I work in an residential home that has absolutely NO state involvement whatsoever. It was donated by a lady for elderly individuals to live in.

It's the strangest place to work. Really theres no rules and we make up our own regulations. No HIPAA involved or anything.

Okay - here's my delimma. I have a resident who has obvious problems. We are NOT a medical facility by any means. I'm the only RN and I'm pretty much on call. I go in 3 times a week to check on the ladies and beyond that I am just on call.

The resident I am referring to has obvious liver failure, and has a DNR in place. By obvious liver failure I am saying her belly is huge and on top of that seems to have some sort of bowel obstruction (tympanic sounds). I have pretty much begged her to go to the hospital/doctor. She flat out refuses both. She is of sound mind. She simply wants to die where she is.

Is there any point where I have to force her to go to the doctor? Her doctor is more than willing to call in orders (as she is now having back pain - which I believe is signaling kidney failure possibly) and with the home being her POA and having the living will in place AND being of sound mind. Is there a point in which I have to tell her she HAS to go in? She's 95 years old. She is just too tired is her reasoning to NOT go to the doctor. She has been ademant about this ever since I have been the RN there (about 1 month). The previous RN had also tried to get her to go and she refused then too.

Help - please I really don't want to force her to go if it's against her wishes. I just need to know am I doing the right thing by not forcing her to go.

I appreciate all of your input in this issue because I'm at a loss.

Thanks

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Jen - I didn't realize places like that existed. You sound like a very caring person, but put yourself in her place - she's 95 yo - hasn't she earned the right to die in the place she calls home?

That said, does she require extra care? Is there someone there to help her?

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Specializes in OB, ortho/neuro, home care, office.

Well - we have aides on all the time - but none of them are trained. They are basically aides though. They cook, clean up after the ladies get them to the restroom, basically provide total care while I'm not there. It's been running like this for over 100 years. So there's no reason to change it. But it's a new board (all new) and I'm doing my best to make changes to make it safer for everyone involved. So that if ever state did get involved (it was donated with the specific requirement that state never get involved) - it would be most of the way compliant with everything. I have worked really hard in the last month to make sure everything is safe. It was scary when I started there.

Anyway - I agree she has a right to die there if she wishes. But I still would love more feedback. Thanks for yours.

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talk with md and see what he see down the road . in nonemergency situations s/he would be the one to make order for transfer

we have a facility similiar to that one here in town: it is a new facility but it is 100% private pay..aides are not required to have certification, pts have a choice eating in room or in a dining hall, that looks like a up scale resturant [sp] i know that they have 24hour nurses residients have a choice of taking meds from nurse on duty, keeping their meds in their room for self-meds, or having a private duty nurse

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Specializes in Critical Care, Cardiothoracics, VADs.
Help - please I really don't want to force her to go if it's against her wishes. I just need to know am I doing the right thing by not forcing her to go. I appreciate all of your input in this issue because I'm at a loss.Thanks

Come on now, do you really need our input to tell you that not only is it not your choice to "force" an orientated adult to seek medical help, but it is illegal?

If adequate analgesia is your worry, sounds like a better plan may be to talk to this lady about the dying process, and her wishes, and the need for pain relief. Maybe she doesn't want to die in hospital but would let a doctor come and prescribe pain meds (do you have a private doc that does home visits?) etc etc.

She sounds scared of dying in hospital alone. She's 95, and she's earned the right to die wherever she pleases.

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Specializes in OB, ortho/neuro, home care, office.

First of all - what you described is EXACTLY what we have here. EXACTLY - but no doctor visits the home - we have to take them in. So - that's why I'm asking. I never thought I would be in a position like this. I didn't think it was legal - or even ethical for that matter. I just want imput - I guess. I don't know - maybe just affirmation that I'm making the right choice. I only graduated from nursing school in May of 2005. So this kind of responsibility on ONLY my shoulders and the whole board counting on me to do the right thing is kinda scary I guess. I wanted others imput to make sure I'm NOT doing anything wrong by NOT forcing her to go anywhere.

Other suggestions/imput welcome. It truly just makes me feel better

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Specializes in LTC, Hospice, Case Management.

Keep in mind, this is just my opinion:

1. You stated that the "home is her POA". A "home" can not be a POA, it must be a person, not a place. You might want to clarify exactly who that is.

2. BUT, as long as she is of sound mind, even her POA can't MAKE her do anything!

3. If this were me, I would be really nervous in your shoes. I have heard of these kinds of homes. Actually, I think they are not really a bad idea, and I don't see how they could be illegal as long as decent care was provided (ya know.. like no one would be able to substantiate a claim to adult protective services), BUT as a licensed nurse, I would be scared that one silly thing would go wrong or a family member would THINK it was wrong and it would be my head on a platter. I know this can happen in ANY nursing situation, but a hospital/nursing home/any licensed agency is going to fight some frivolous (sp?) lawsuit and stand a good chance of winning, but who's going to stand in your concern in this situation? Believe me, I am no expert and could be wrong.. but this would make me nervous.

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I'll echo what the others have said - if she's of sound mind, you can't make her do anything.

When I'm on the ambulance, we run into a lot of consent issues. Bottom line: I couldn't come into your home and whisk you away to the hospital against your wishes just based on my assessment of you.

What I can do: communicate as clearly as possible why I think you should go, make sure you fully understand the ramifications for refusing to go, and even get my medical director to talk to you. If that fails though, I just have to accept it, document accordingly, and go on my way.

I agree with Nascar Nurse though. As a fairly new grad myself, two things would be really scary to me if I were in your position: a) the fact that you're in a position where you have to make policy and procedure changes, and b) that you don't have other RN's at work to exchange ideas and share the workload.

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Specializes in LTC, Hospital, Staff Development.

I understand how difficult this must be for you. I have been in LTC for several years and have been in LTC management for most of the time. Resident's have RIGHTS. Be it a nursing home or private care home(often referred to as Adult Family Home), and even Assisted Living. If your resident is a 'DNR', that specifies what you do 'if' you found the person without heart beat or breathing. DNR does not specify exactly what one is to do for someone who is refusing medical treatment. However, in the LTC facilities I have worked in, when we have a resident who is of the same mind-set as the patient you care for, we honor their wishes. Some things you need to chart in the resident's record or keep personal charting for protection for yourself are: Any Risk vs. Benefit of not complying with medical/nursing treatment, and make sure your resident understands there is a very real risk of dying by refusing medical treatment, chart that you have alerted the resident's MD and any family member or Durable Power of Attorney of the resident's wishes. If the home has a MSW, alert them, to. Please offer and chart offers of Hospice services to the resident. If you are concerned that your resident is suffering and will ultimately die, offer Hospice Services, or recommend your employer offer Hospice to the resident. If you still remain worried, call your local Long Term Care Ombudsman and speak with them annonymously. Alert them to what is going on and ask if they have any recommendations. Call your Board of Nursing and see what thoughts they have on your situation. Better to call everyone in the whole world, than making a HUGE mistake and having to pay the price.

One last thought: I made my significant other, who is a nurse, also, promise to honor my wishes. My wishes are if I get a disease that causes dementia or Alzheimer's (or any other brain trauma/injury/brain disease), that my significant other will honor my wishes and allow me to die. Do not force me to live beyond what nature intended.

Good luck!

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