I'm a nurse at an Alzheimers Assisted Living and I would like to get some of your opinions on whether or not alzheimers residents should have the right to refuse meds.
Some of our residents can be very combative and just a couple of days ago the 911 was called because a resident had attacked two other residents. Last night we had a resident poop on the hall way floor and refused to take a shower afterwards. The list goes on and on. I love my alzheimers residents and they literally light up my day when I see them. I would never be the type of nurse to want to violate or take away their rights, however there are just some residents that should not have that right to refuse.
Another thing that bothers me is that since they do have a right to refuse, why is it that we hide crushed meds in their soup, applesauce, or icecream.... just so that they won't notice that they are really indeed being medicated. I feel bad that I have to do this but I know its the only way they'll take it or so I'm told ( I'm a newbie). One night I crushed some meds for Mr. X and put it in his icecream and he said " What do you think you're doing" ( he thinks we try to poison him) and I told him I had a snack for him. He said whats in it ? I said icecream and water ( I put a little water in it to help mix the meds so I wasn't lying). Anyway, I felt terrible. I would feel much better if they did not have a right to refuse so that way I wouldn't feel so guilty " hiding" the meds in applesauce or some other food.
How can a resident that don't even remember their name have the right to refuse?
How can a resident that attacks other residents have a right to refuse?
How can a resident that poops openly in the hallway have the right to refuse ?
Thats a hard one but I think it would have to be a case by case kind of thing. Are they in a place where they are competent enough to make their own decisions in regards to their medical care in general?? Not to mention what are they refusing... If they are having issues with their daily docusate thats one thing but if they are a diabetic refusing insulin that might be something to reconsider... It's so sad having to intervene and take some of the independence away from the patient.
Well, I've seen a few Alzheimer's residents who refuse meds, even when the nurse sneaks it into pudding or applesauce. They still know that it's their medicine. Therefore, the nurses started hiding the medicine in their food, which they ate. (Of course, I'm sure "The State" inspectors would not like this practice.)
The problem seems to be that while we recognise that the patients don't have the ability to comprehend or understand the treatments nor have the capacity to consent or refuse - we, as nurses, still do not have the legal right to hide or sneak their medication. That, is against the law. Technically, it's trespass to the person. The law (at least in Australia) states that any person with CAPACITY has the right to refuse medical treatment. However, these persons do NOT have capacity. So what does the law stipulate in this case (i.e. a patient without capacity is refusing medication.)
Competence is the capacity to understand the nature and consequences of medical procedures to be undertaken. At common law there is a general presumption that an adult person is competent to make decisions about their medical care.
(Ethics & the Law for the Health Professions. Lowe et al., 2009)
Patients with stage 2 and further advanced dementias can be universally agreed, in this situation, not to be competent nor possess capacity. So what do we, as nurses do, in order to protect the best interests of these patients (i.e. medicate them appropriately and or perform other nursing actions such as wound care) without breaking the law (i.e. medicating a person that has refused medication - e.g. by sneaking it into their food - without appropriate documentation that the person is not competent and legal actions to combat the ethical dilemma.
- Does the patient have an advance directive complied prior to lapsing into stage 2 and 3 of dementia where they do not have capacity to make sound judgments that states nursing and medical staff can medicate them, even when they refuse, should it be in their best interest? Probably not - but it seems like a good idea for people in early stages of dementia to consider!
- Does the patient have a "substitute decision maker"? In Australia there are four types, the supreme court in a state or territory, the guardianship authority and appointed guardians, health attorneys or medical agents appointed by the patient or relatives or friends under the 'person responsible' legislation. It seems to me that these patients should have a medical agent that was appointed before the serious decline of the disease, a guardian appointed by the guardianship tribunal (or equivalent in the US) or a relative or friend defined as person responsible.
If the patient had a "person responsible" then they could authorize the nursing staff to "hide" the patient's medication in their food/whatever they need to do in order to get the meds into the patient. Therefore, legally, the nurse is not trespassing against the patient - nor causing assault in any way (which is technically what you're doing without consent from the appropriate person.)
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 :)
And sometimes getting another nurse -- one they decide they like better that day -- to give the med instead helps too...
Had that happen A LOT when I worked Geriatrics. A patient would violently refuse a med for another nurse and then, minutes later, I'd come up and she'd smilingly and sweetly take it from me. And I had times when the same exact patient wouldn't take it from me but would take it from the other nurse. Or from neither of us and spit the meds at us. Gotta love this population!
Care conferences, IDT meetings and care plans are all about these problems. The individual patient's behaviors should be documented thoroughly, the appropriate referrals made for assessments, and interventions determined by the physician, SW, nursing staff and family members. Then all of the documentation, assessments and interventions need to be rolled into a comprehensive care plan.
When all of the i's are dotted and t's are crossed, and everyone is in agreement about how the individual's behavior is to be addressed AND EVERYONE is consistent about doing it that way, the staff will be totally covered in its actions.
This can be a tough one...not everyone with diagnosed Alzheimer's is that bad off, some do retain some capacity to understand things. It helps to know the patients...something that isn't easy to do if your facility enjoys 'floating' staff around like chess pieces!
I always decide based on the individual. Sometimes you have a behavioral issue with someone, they really DO need that Seroquel or Tegretol. So, I'll use the 'hide it in ice cream or Ensure' trick. But, sometimes "No", means "No"...they just won't take it, no way, no how. You can try and reapproach later, often with success, but sometimes they just won't go for it. Then I'll document "Refused", and let the supervisor know. It's up to her to call the doctor and find out how to proceed. It is not up to me to hold 'em down and force the issue.
I had a supervisor one night, (a real idiot, by the way) who tried to tell me I had to get a couple of CNA's and try to force the meds in to a resident who was acting up, very physically, and aggressive. I told her I had made several good faith efforts, without success, and I was documenting it as "refused". She told me that this resident had Alzeimer's and was unable to refuse. So, I handed her the Ensure with the meds and told her to have fun! I told her I'd be sure and call 911 so's the ambulance would get here quick to take care of her. She took one look at this guy and decided to accept my explanation.
The point is, they may not have the so-called "legal right" to refuse, but then YOU tell me how to get it done when they just won't take it! Short of physical assault, that is...
well let me ask this.............if someone is refusing to take their meds and the nurses started out hiding it in his ice cream, pudding etc. and was working and then stopped...........and of course they said oh he said no and we cant hide it..........why the heck doesnt someone then inform the relatives that someone should then become the legal guradian.........i was the poa but no one ever gave me the option to become the guardian and now its too late..........my father is dead...........but i think its absolutely ridiculous when you see that they are in stages 2, 3 etc. cant say a complete sentence let alone an audible word.........etc. and they can refuse the meds and they know what they are doing? this is absolutely a disgrace and I wish someone had informed me................didnt know i had to have a lawyer tell me this..............a professional so called doctor or nurse couldnt suggest this to me or is this against the law too?
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.
well let me ask this.............if someone is refusing to take their meds and the nurses started out hiding it in his ice cream, pudding etc. and was working and then stopped...........and of course they said oh he said no and we cant hide it..........why the heck doesnt someone then inform the relatives that someone should then become the legal guradian.........i was the poa but no one ever gave me the option to become the guardian and now its too late..........my father is dead...........but i think its absolutely ridiculous when you see that they are in stages 2, 3 etc. cant say a complete sentence let alone an audible word.........etc. and they can refuse the meds and they know what they are doing? this is absolutely a disgrace and I wish someone had informed me................didnt know i had to have a lawyer tell me this..............a professional so called doctor or nurse couldnt suggest this to me or is this against the law too?
Bolding is mine.
This is the rub, though......it sure seems we all can agree on the fact that technically, no, they "can't" refuse if they don't comprehend/understand what that means. It's all right and good to say, they are incapacitated. We KNOW that already. The trouble comes from HOW HARD CAN YOU TRY/WHAT CAN YOU DO to actually MAKE them take something? If they take a bite of ice cream with crushed meds in it with no problem....great. If they are violent and yelling and will have nothing to do with said ice cream....it doesn't really matter if they are "incapacitated" and "unable to refuse." You have no means to make them take it anyway.
houseoflove214....what would you have had them suggest to you? That they put the meds in applesauce? Ok, so they suggest it and you agree. However, your father still won't take the meds. What would you have them then do?
Whether or not someone CAN legally refuse or not can sometimes be irrelevant. Just because they "can't," doesn't mean they won't, and you can't really hold someone down and FORCE a med down their throats. It would be nice if there was a clear answer to this question; unfortunately, there is not. The answer will vary from client to client. If they do not have the cognitive ability to legally refuse, it is acceptable to offer the meds in pudding or applesauce or ice cream. I don't see the problem with that. If they spit out the meds, throw them at you, etc...to me, that is a "refusal." "Legal" or not. To use any further action to get their meds in them would be battery.
Specializes in Infectious Disease, Neuro, Research.
HoL214 (if I may abbreviate), I don't know that anyone can answer your specific situation. Having POA, in most States, you would have had any necessary decision-making authority. Being a "guardian", "Legal representative", etc, is generally a difference in terminology between States, not(generally) in practical application, until you get into finances. Having said that, as noted, if a person is mentally incapacitated, but physically very capable, we generally won't endanger either the patient, or ourselves, forcing medication.
I have received patients(in the hospital, not at a LTC) with broken teeth, lacerated mouths and broken hands/arms and aspiration, from someone deciding that they would MOST CERTAINLY take their meds. Obviously, this is reported and prosecuted, but I can understand the frustration, when given an impossible task with a recalcitrant/combative patient.
IME, if maintenance (important) meds are missed more than 24 hours, family is usually notified- if they are available. Each facility should have a policy regarding this. Unfortunately, this is an area where the situation will never be clear. If a caregiver has had a fistful of feces thrown at them 2 hours ago, and been clawed with the feces-coated nails, yes, they probably will document, "pt. refused", the next time they have to pass meds, if they have any suspicion of violence.
State law, and institutional policy should give pretty clear direction. for the severely incapacitated, "trespass of person" would not generally apply, unless some injury resulted from med administration.
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.
I'm guessing you use a different staging system than I am used to. The one I am familiar with has 7 stages with 7 being the most severe. Stages 2 and 3 include mild, often unnoticeable symptoms that can include forgetting someone's name after meeting them, or losing things, which means I could already be classified as a stage 3 myself, although I don't think I'm too far gone to make medical decisions.
Basically, without a court order or use of one of the temporary options, they can refuse. None of the options in a conscious patient allow the Nurse to make the decision on their own to covertly administer drugs without being guilty of assault.
In order for a refusal of treatment to be 'legal', the patient only needs to be aware of the potential consequences of refusal, they don't necessarily need to be "in their right mind". If they aren't aware of the consequences you still can't covertly administer the med, at least in my state, on your own as a Nurse.
My state's rules on this are: Administering a med without any form of consent is assault. Consent can be implied in the case of a medical emergency, significantly decreased LOC, or significant drug effect (vent sedation for instance), but not mental illness. Consent can given by a POA, but only when the patient has been deemed incapacitated by the proper procedure which is: Two Physicians can declare a patient unfit to make decisions for 72 hours, then they must be seen by a LMHP who agrees with the MD's and that order will last 14 days, after that there must be a court order to covertly administer medications.
NurseLoveJoy88, ASN, RN
3,959 Posts
thanks for the replies.