Resident's right to refuse? Or NO right to refuse?!

txspadequeenRN, BSN, RN · May 14, 2008

your clinical instructor is wrong wrong wrong!!!! you can get into some serious mess for forcing treatments on a resisting patient. my advise to you is to offer the treatment x3 at various times during the day if the patient continue to refuse tell the charge nurse.i cannot believe a instructor would put you and your class mates in this position.

i am an lpn student close to graduation.
today at clinicals in the etended care facility, i had a resident refuse "skin prep" to her heels. she was in the hall in a wheelchair. she didnt just say "no" , she screamed that she did not want it,while planting her feet firmly on the floor. tried explaining what it was for, that it did not hurt, would only take one minute. i tried.
no!!!!!!!!!!!!!
charted in the tar her refusal. told her nurse. no problem.
husband comes in in the afternoon. she tells him we tried to force her into it.
clinical instructor informs me that the pt does not have the right to refuse "cause she isn't in her right mind." and i could lose my licence for "not doing the treatment".
i told her exactly how she refused. practically kicking and sceaming. literally.
she says, "doesnt matter. just do it quick."
isn't this against the law?!
the pt remembered well enough what happened that morning, to tell her husband about it in the afternoon. she fully understood what i wanted to do.
but "she doesnt have the right to refuse" ???!!!
help !
one of us will have her again tomorrow morning!
and if she refuses again, our instructor will try to force us to do it anyway .

Daytonite, BSN, RN · May 14, 2008

well, i worked in ltc for many years as well as studied the federal ltc laws and the california state laws for long term care facilities and i'm here to tell you that your instructor was very wrong. did you know that there is a federal law that gives the patient the right to refuse a treatment? if a treatment is forced on a patient and it is reported to the state department that monitors the nursing homes in your neck of the woods, the facility could get into a lot of trouble. in addition, to force the patient to accept the treatment would be close to battery or assault. i would mention the patient's refusal of the treatment to the charge nurse first thing tomorrow morning; ask if this patient has done this before and what they do about it. every facility has a way to handle refused treatments--it isn't by forcing or tricking the treatment on the patient! shame on your instructor for not knowing that! shame on her for even suggesting what she did. did other students hear her? if so, you might get together and document this in a letter, all of you sign it and give it to the head of your nursing program. you don't need a clinical instructor like this teaching you, but your nursing program can't know she's doing this unless you document it and tell the bosses.

elkpark · May 14, 2008

Well, now, hold on a minute -- nobody's mentioned the client's legal status. If someone has been legally ruled incompetent and has a court-appointed guardian, then that person no longer has a legal right to refuse medication or treatment; the consent is the guardian's to give or withhold.

I'm not saying the instructor's right, because I don't know what the instructor knows about the client, and, if it's the case that there's a guardian and this is a regular situation (refusing the heel treatment) and everyone except the student knows about it, it would be nice :rolleyes: if the instructor explained to the student(s) how this works beside saying, "Just do the treatment!" "She's not in her right mind" is certainly not a very helpful or enlightening explanation, if, indeed, that's what the instructor was trying to communicate (that the client has a guardian).

But it does raise the issue (which comes up commonly in LTC) that there are situations in which a client doesn't have a right to refuse, and it's important to know the legal status of your client(s) and the relevant laws/regulations in your state. :)

Chanzes MiMi · May 14, 2008

Well, now, hold on a minute -- nobody's mentioned the client's legal status. If someone has been legally ruled incompetent and has a court-appointed guardian, then that person no longer has a legal right to refuse medication or treatment; the consent is the guardian's to give or withhold.
I'm not saying the instructor's right, because I don't know what the instructor knows about the client, and, if it's the case that there's a guardian and this is a regular situation (refusing the heel treatment) and everyone except the student knows about it, it would be nice if the instructor explained to the student(s) how this works beside saying, "Just do the treatment!" "She's not in her right mind" is certainly not a very helpful or enlightening explanation, if, indeed, that's what the instructor was trying to communicate (that the client has a guardian).
But it does raise the issue (which comes up commonly in LTC) that there are situations in which a client doesn't have a right to refuse, and it's important to know the legal status of your client(s) and the relevant laws/regulations in your state. :)

My instructor had never met this pt., and had no knowledge of her status, besides that she had a stroke. In her mind, ANY pt with a medical condition cannot refuse. But I do understand what you are trying to get across. Thank you everyone for replying.

Daytonite, BSN, RN · May 15, 2008

it doesn't matter if the patient was declared incompetent and has a guardian, if the patient raises their voice and says , "no!" or otherwise acts negatively to something you, the nurse, want to do with, or to them, you had better stop at that very moment, re-assess and re-strategize. an order of guardianship or a healthcare power of attorney doesn't give any healthcare worker a pass to violate the patient's right to humane and compassionate treatment. you don't make comments, especially to trainee nurses, like "doesn't matter. just do it quick." i've worked as a staff nurse and supervisor in ltc. had i heard this instructor say this i would have pulled her aside and talked to her, written it up and reported the instructor her to her supervisor as well as the don of the facility. that was the incorrect way for her to teach her students and act as a mentor. she would have put the facility in serious trouble if one of her students had gone ahead and done this treatment on the patient per her direction and amid the patient's protests no matter how innocuous the treatment was (skin prep to the heels is normally a prophylactic measure, but it burns if there are open areas in the skin and then it would be inappropriate to be doing). her husband could have legitimately filed a complaint of abuse against the facility, as it would have been a clear violation of the patient's rights. as a charge nurse, if this treatment was causing such a problem, i would reevaluate it's worth to the patient, call the doctor and get it changed or d/c'd.

http://www.cms.hhs.gov/certificationandcomplianc/12_nhs.asp
- http://www.access.gpo.gov/nara/cfr/waisidx_05/42cfr483_05.html - the nursing home federal laws; click and open up the text on the third topic (sec. 483.10 resident rights)
  - http://edocket.access.gpo.gov/cfr_2005/octqtr/42cfr483.10.htm

txspadequeenRN, BSN, RN · May 15, 2008

.....:yeahthat:....

it doesn't matter if the patient was declared incompetent and has a guardian, if the patient raises their voice and says , "no!" or otherwise acts negatively to something you, the nurse, want to do with, or to them, you had better stop at that very moment, re-assess and re-strategize. an order of guardianship or a healthcare power of attorney doesn't give any healthcare worker a pass to violate the patient's right to humane and compassionate treatment. you don't make comments, especially to trainee nurses, like "doesn't matter. just do it quick." i've worked as a staff nurse and supervisor in ltc. had i heard this instructor say this i would have pulled her aside and talked to her, written it up and reported the instructor her to her supervisor as well as the don of the facility. that was the incorrect way for her to teach her students and act as a mentor. she would have put the facility in serious trouble if one of her students had gone ahead and done this treatment on the patient per her direction and amid the patient's protests no matter how innocuous the treatment was (skin prep to the heels is normally a prophylactic measure, but it burns if there are open areas in the skin and then it would be inappropriate to be doing). her husband could have legitimately filed a complaint of abuse against the facility, as it would have been a clear violation of the patient's rights. as a charge nurse, if this treatment was causing such a problem, i would reevaluate it's worth to the patient, call the doctor and get it changed or d/c'd.
http://www.cms.hhs.gov/certificationandcomplianc/12_nhs.asp
http://www.access.gpo.gov/nara/cfr/waisidx_05/42cfr483_05.html - the nursing home federal laws; click and open up the text on the third topic (sec. 483.10 resident rights)
http://edocket.access.gpo.gov/cfr_2005/octqtr/42cfr483.10.htm

GingerSue · May 15, 2008

is it possible to find out the reason that the client is refusing?

anne_in_maryland · May 15, 2008

I have worked in a nursing home for 5 years. I have to tell you IRL, if a patient is not making their own medical decisions we would go with whatever the order says. Now, you have to take that on a case by case basis. You can't shove meds down someone's throat unwillingly. But, if the patient is deemed incapable of making medical decisions, I could see just putting the lotion on.

morte, LPN, LVN · May 15, 2008

I am an LPN student close to graduation.
Today at clinicals in the etended care facility, I had a resident refuse "skin prep" to her heels. She was in the hall in a wheelchair. She didnt just say "No" , she screamed that she did not want it,while planting her feet firmly on the floor. Tried explaining what it was for, that it did not hurt, would only take one minute. I tried.
NO!!!!!!!!!!!!!
Charted in the TAR her refusal. Told her nurse. No problem.
Husband comes in in the afternoon. She tells him we tried to force her into it.
Clinical Instructor informs me that the pt does NOT have the right to refuse "cause she isn't in her right mind." And I could lose my licence for "not doing the treatment".
I told her exactly HOW she refused. Practically kicking and sceaming. Literally.
She says, "Doesnt matter. Just do it quick."
Isn't this against the law?!
The pt remembered well enough what happened that morning, to tell her husband about it in the afternoon. She fully understood what I wanted to do.
But "She doesnt have the right to refuse" ???!!!
HELP !
One of us will have her again tomorrow morning!
And if she refuses again, our instructor will try to force us to do it anyway .

shouldnt have been done in the hallway.....surprised instructor didnt have a prob with that.....

Chanzes MiMi · May 15, 2008

I was not attempting to apply it in the hallway.

I explained what it was, what it was for, and was going to take her to her room to apply it. That is when she began to scream and firmly plant her feet on the floor, so I could not wheel her into her room.

This was in front of the nurses station in front of other residents and family. My instructor wanted me to forcibly take her to her room and apply it, even though she had screamed "No".

She said she did not want it, she did not need it, her feet were fine. And yes, I did explain this was to help keep her heels healthy.

classicdame, MSN, EdD · May 15, 2008

even crazy people have the right to autonomy. I do not agree with your instructor.