Should Alzheimers Clients have the right to REFUSE medication ?

rachelgeorgina · Sep 14, 2009

Some patients with dementia in the early stages (though that doesn't sound like what you're dealing with here) can be very lucid and aware. My great auntie was in stage 1 of dementia when she was dying and was assessed to have the capacity to refuse life sustaining measures (such as CPR and intubation). However, the residents you sound like you're dealing with obviously don't have the capacity to consent or refuse this sort of treatment. If they truly have the right to refuse, then hiding their medication in their food is illegal. As far as the law states - any competent person assessed to have capacity has to right to refuse medical treatment. You're, legally, assuming that these residents have the capacity to refuse. They don't. Give them a mini-mental - they'll almost all fail it dreadfully. Ask them if they understand what the medication is for and why they need it - most likely, the answers won't be of any use to you.

It sounds like these residents should be under (what we call in Australia) guardianship, which entitles someone else (WITH capacity) to consent to or refuse medical treatment in that patient's best interests. That person can be state appointed or a family member/friend. In this manner, the patient is well cared for, legally - and probably won't know any different, either.

TheCommuter, BSN, RN · Sep 14, 2009

I've worked with elderly people who have been afflicted with Alzheimer's disease during the entire course of my short career in nursing.

Sorry, but these people no longer have the mental capacity or cognitive functioning that is necessary to make an informed refusal. Therefore, I do not feel that they have the right to refuse medications, treatments, and basic care.

For example, I had a demented little old lady as a resident at a nursing home where I was employed several years ago. She continued to refuse food and fluids on a daily basis for several weeks, and the staff kept documenting that the resident "refused dinner." Her daughter was aware of these refusals.

Her BUN was at a baseline of 20 before these refusals started, but it crept up to 300+ by the time she was sent to a local hospital. She ended up dying of renal failure.

She did not have the cognitive functioning that is required to formulate a completely informed refusal, and I'm certain she didn't know she was going to eventually die after continually refusing care.

You can let a demented person with Alzheimer's disease refuse, but please be prepared for the fallout when the outcome is poor (or fatal).

NurseLoveJoy88, ASN, RN · Sep 14, 2009

When they refuse I still educate them on the drug and and benefits of taking it. And everytime they refuse I don't give it and document they refused. However, I was told that some resident will never take their meds so I must put it in something. This makes me feel bad but at the same time if we don't give it the resident is a risk to staff and others.

I'm going to discuss my concerns with my supervisor, not saying its going to change the law but maybe I'll have some more insight on this issue.

JomoNurse · Sep 14, 2009

i don't think they should have the right to refuse. they are not in their right state of mind - no matter how aware or "with it" they seem. as nurses we know that the medication is going to benefit them, and not harm them. they don't and can not understand that. the problem emerges when trying to get them to take it (sneaking it in their food, or whatever clever way you can think of)

NurseLoveJoy88, ASN, RN · Sep 14, 2009

i don't think they should have the right to refuse. they are not in their right state of mind - no matter how aware or "with it" they seem. as nurses we know that the medication is going to benefit them, and not harm them. they don't and can not understand that. the problem emerges when trying to get them to take it (sneaking it in their food, or whatever clever way you can think of)

I agree. What should be done about this ??? This is a problem.

TheCommuter, BSN, RN · Sep 15, 2009

When they refuse I still educate them on the drug and and benefits of taking it.

You can educate a patient with Alzheimer's disease until your voice becomes tired, but most members of this patient population lack the cognitive ability to funnel any new patient education into their long term memories. They're going to remember virtually every detail of their wedding day 60 years ago, but they encounter severe problems when attempting to formulate new memories.

Therefore, patients in stages 2 and 3 of Alzheimer's disease do not possess the mental capacity to engage in informed refusals. They are mentally incapacitated persons.

JenniferSews · Sep 15, 2009

I agree with everyone that stage 2 and 3 alzheimers pts don't have the cognitive abilities to fully understand your explanation or why they are refusing the meds. Maybe if you asked them why they are refusing, that might help you? I know it's not the best or most politically correct but when I was young I would sometimes equate alzheimers pts with children. If my 3 year old refuses a med for a reason that wasn't logical or realistic, I would hide it in some ice cream too.

I commend you on your thoughtfulness and caring for your patients, I know you are the type of nurse I want caring for my Nana who was diagnosed with alzheimers 7 years ago. But I would also want very much for you to make good decisions for her and medicate her if it was necessary even if she didn't understand why. I would want you to do the same for me in that position as well.

EverNurseRN · Sep 15, 2009

side note-with this population reapproach is key..they may be angry and refuse right then but 5 min later take it no problem..make sure ur documenting multiple attempts :)

lisamc1RN, LPN · Sep 15, 2009

Is your facility making sure that these residents have guardians? When they become mentally incapacitated like that, they need someone to look out for them. Once they have guardians, you can ask the guardians for permission to hide the meds in something and get a doctor to agree and you are covered. We hide meds in a couple of our residents food or drinks, per guardian requests and doctor order. I wouldn't feel comfortable hiding the meds otherwise. Of course, chart all refusals, all attempts and the outcomes of not taking the meds.

Ruby Vee, BSN · Sep 15, 2009

i've been a nurse for over 30 years and a daughter for over 50 years. my mother has alzheimer's as does my mother-in-law and my godfather. my specialty is sicu, not assisted living or memory care, so my opinion in based mostly on my experience as a family member.

mamita, my mother-in-law is in her 80s. she's on a locked unit due to her propensity for running away. she still recognizes her children but no longer recognizes their spouses or her grandchildren, cannot hold a coherent thought for even a minute and is no longer capable of showering, dressing or toileting herself. she's angry all the time and the only clear or coherent thing she's said in the past few years is that she wants to go home and live by herself. she's in good physical health despite her diabetes, and we her children are convinced she's going to outlive us all and become a burden to her grandchildren. do i think she has the capacity to make an informed decision about refusing her medication? not at all. but do i think the staff should force it into her? if she doesn't want to take it, don't make her! what's the worst that can happen? well, i guess she could die. there are worse things than dying, though, and i think she's already living in hell.

my godfather no longer recognizes anyone, including his wife except on the rare good moment. he fell recently, hitting his head, breaking a hip and a collarbone. this was his second fall in two weeks. he's in the hospital now, restrained, tubed and forced to take his medications. he has teds and scds, which he hates. he doesn't understand the concept of dvts, and he doesn't want to wear the damned things. i can't blame him. i wouldn't want to wear them, either. he doesn't like the feeding tube and keeps ripping it out. ditto the foley. his wife and her daughters, both of them nuns, know how miserable he is, but they insist on replacing the lines and tubes, forcing the meds and keeping him restrained so he can "get better" and "go home" to the locked memory unit where he's resided for the past few years. the poor man is incapable of any self-care, doesn't remember his family, cannot communicate with them or share old memories. he's been married to his current wife only a decade and no longer remembers her as his wife, but as the wife of a close friend as she was 50 years ago. evidently he didn't like her much then. even the nuns admit that his existance -- and their mother's -- has been miserable. but they remain focused on keeping him alive at all costs.

and then there's my mother. she still remembers her friends, children, nieces and nephews, and every resident and caregiver in the assisted living. she doesn't always remember names, but she knows that the night aide is the granddaughter of dad's high school buddy and that the director went to school with my sister. one of the ladies who shares her table for meals used to run the drug store where she did all of her business for decades and another is the mother of a woman my mother worked with for 25 years. every day when i call her, she's thrilled to hear from me and although her short term memory is such that i can tell her the same story five or six times in a half hour phone call and it's new every time, she can tell me stories about when her mother took the train out west to teach on an indian reservation at the ripe old age of 19 and about the time my great grandfather lost three fingers changing a tire, and then had to drive himself to the hospital. she likes her room at the assisted living, she loves the food and repeatedly tells me how good the staff have been to her. she's the one i'd be most likely to try to keep healthy by sneaking medication into her nightly dish of ice cream. she's still interested and interesting, enjoying her life and reasonably happy. mamita and my godfather are merely existing in hell.

iwanna · Sep 15, 2009

Most of the patients with dementia have a medical power of attorney that will sign consents form for their meds. In a psych hospital we always crushed their meds, and disguised them in food or drink. Most of them refused their meds, and it was the only way that we could give it to them. Usually the med was for the alzheimers, such as exelon or can't remember the name of some of the others?? uh-oh! I never felt bad about sneaking these meds into these patients, as we had consent from family members. It was for the pts. best interest But, I did have a problem when pts. had feeding tubes. I would never want a feeding tube. I told my family that, if I can't eat the normal way, then I don't want to have feeding tube to merely exist.