The right to refuse has so many interpretations

Nurses General Nursing

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Inside one nursing home I have been adamently told, "You should not force her to do anything..." about an ill patient who said she wanted to stand up but was too weak.

In the same facility on other patients and other shifts, I have heard the phrase, "You have to....."and I have heard a charge nurse say, "Nope, nope nope, she HAS to come downstairs," in response to me saying, "She needs to finsish her breathing treatment."

In school, I was taught, "You can use powers of persuasion but you can't force them," ie, "They are all afrain you might fall out of bed..."

Some nurses still insist, "She has a right to refuse," and end off the conversation. They won't lilsten to any discussion about this.

Specializes in Pediatrics, Emergency, Trauma.
Okay...I completely agree....I don't want my gangrenous leg cut off...that is my decision.....I want to smoke, eat double bacon cheese burgers and milk shakes, yes. I am old, confused at times, not legally declared incompetent, I itch and stink because I am so dirty because I keep telling the CNA I don't want a bath. I feel stuffed, bloated,, bad stomach pains because I haven't pooped in a week but keep telling the nurse " I don't have to take that medicine" and you as my wonderful caring nurse just let me lie there?

Nope....I still want Brandon

^I think I want Brandon too :nailbiting: seriously!!!

FWI, I am sure most of us, including Brandon, are generally ethical in our practice, bottom line.

When the instances where patients refuse their meds-RARELY happens now; working in Peds, there is more negotiation and meds are given, or put in a tube or IV-I found myself "on to the next patient" in LTC, while in Sub-Acute, I found myself having the ability to assess the refusal, especially if it was a blood thinner, had a new onset diagnoses that would factor in the higher susceptibility of throwing a clot, plus post op issues; and collaborating with the provider for a follow-up.

I just find myself when I worked in LTC, more inclined with the "they are at home" mantra hammered in...I would mention that they haven't had a BM in a week...especially if they start to be concerned with moving their bowels, they seemed more receptive in getting at least one of the three stool softeners, PLUS a MOM, or dulcolax.

I never thought to do a blanket "what your doctor ordered" because most still know what a colace looks like...my pts would skip the red pill but like the senna if they want their choice, and they examine their pills meticulously, even as someone with Dementia, you NEVER know when the moments of clarity come through.

On the other hand, I would want someone to make sure I was giving meds, turned, etc if I ever lose that cognitive ability...however, I am hoping for a serum to prevent that in the future, or hope that I will get a quality nursing teamto take care of me at home. I don't want to be neglected or my wishes to be dismissed either, however, I know I would need to be coaxed out of bed in order for a better quality of life; I just want it done with respect.

I think if someone decides they want to stink for days they better get a private room.

What an interesting thread! So many important points mixed up with so many emotions topped off with facility procedures and followed by family needs that often take precedence over the patients/residents' wishes/requests! It's a right mess for the nurse to have to deal with who's actually giving care and is a 1st hand witness to the best plan of care (note I said best plan of care and not care plan... and if you don't get the diff, I am unable to explain it to you).

Some random thoughts after going thru the whole thread...

Brandon, you may be my nurse. I get you get it.

Not all falls are preventable. Even with fall precautions. Even with 1:1 monitoring.

High fall risk ppl with dementia may refuse fall precautions. Does that mean we should not implement them anyway? Do they not also have the right to be safe?

No, elderly ppl are NOT children, they just act like it sometimes because of dementia/mental illness. Get the diff.

Let them eat cake.

I'll stop here because I can feel myself getting all worked up about this topic and I want to respect the thread and not go off an a huge rant directed at specific posters. I'd like to conclude this post with great disdain and sorrow for policy that prevents me from giving the best/safest care without having to jump thru numerous hoops to no avail. I'd also like to NOT thank some doctors for understanding that 0.5 mg ativan prn agitation is a JOKE.

Specializes in ortho, hospice volunteer, psych,.

I had a stroke caused by an aneurysm the day after my 54th birthday. The way people, including many healthcare givers, treat me varies widely. My mind wasn't affected, thank heaven. My body, however, is another matter. My speech was very profoundly affected as was my balance. People's reactions vary from, "Would she like a balloon?" to treating me like my usual self.

Any rancor in previous posts is because I have had a look at my future. People do assume. Right now and for as long as I remain cognizant, I demand to be treated with respect and dignity! And after! If I'm questioning a green pill that I never had before, it's not to be difficult, it's because I remember just how easy it can be to make an error. I may not be able to be a psych nurse anymore, but I still hold a BSN and an MSN and that information is still locked inside my head.

I think most of us will be much more reasonable and cooperative if we are treated as though we matter, aren't called "Sweetie" and "Honey" and our remaining hair not put up in Pippy Longstocking-like braids/ponytails, and if we are at least listened to, we'll be a great deal happier. The home is now where I live! If I want to hole up with my laptop or tablet all afternoon or read my Kindle into the night, So what?

As far as showers go, I had one aide in rehab, who was gentle and caring. Her counterpart might as well have scrubbed my back with the john bush! Wouldn't have been any rougher! Guess which shower I'd have loved to skip?

Ok, I knew I'd ruffle some feathers with my post.....

I just want to clarify, that I never said I advocate forcing anybody to do anything against their will. People are reading too much into what I said. Telling a demented elderly resident that their daughter wants them to shower (which they do) or handing an elderly resident some MOM and telling them it's medicine (which it is) is not abuse.

If the resident still refuses to take a shower, of course I'll let it drop and try later. And if the resident asks to know specifically what the white minty stuff in the cup is, of course I will tell them.

But for a nurse to just say "ok" and walk away when a resident refuses a shower is NOT good nursing. And for me to say "here's your laxative" to a constipated, confused resident who refuses any and all bowel care would just be stupid. I mean, if we really want to go down that road, I know all the nurses here do NOT tell every resident what every med is when handing them a cup of pills.

My whole point was we can't just give up all attempts to treat and medicate LTC residents when they say "no". I have a cataclymically demented resident who clearly hates all hands on care. He is also totally incontinent of bowel and bladder. Are we to stop cleaning him up? Let him lay in filth?

Maybe I should have been more clear in my saying that these residents are in no way of clear minds. If a totally a alert and oriented resident refuses to bathe or have their briefs changed, well tat calls for a SW eval or something. If the completely demented resident resists personal care, we proceed with gentleness and patience and soothing voice, bit we DO clean her up. To say "oh she refused" would be clear neglect. Am I missing something here?

I never said I wouldn't tell them what the milk of magnesia is..... if they asked. My saying "it's medicine the doctor ordered" is 100% the truth. Not a shred of a lie in there. If they asked what it specifically is, well, of course I would say it's milk of magnesia and tell them it's a laxative.

I'm failing to see the ethical dilemma here. These aren't alert and oriented residents we're talking about here. If they were, they would have spoken with the doctor and had such medications stricken off their MAR ages ago. The residents I'm talking about would refuse their BP meds too because in their minds "they don't have no high blood pressure". And don't even get me started on how many would refuse the lasix.

Do they have the right to refuse? Absolutely.

Am I obligated to explain to them what every med is, every time I hand them a cup of pills? Absolutely not, unless they ask.

It's not a "lie by omission". Realistically, no nurse in any nursing home ever would EVER complete a med pass if explaining what every pill was was a required part of the process.

One last thing I want to point out:

I think a huge part of the misunderstanding here stems from the fact that people are assuming when I say "LTC" or "residents" that I'm talking about some subacute rehab or something. I work in a true LTC facility. It is a home for aged, demented veterans and their spouses.

Yes, if I had an alert 64 year old on a rehab unit who was recovering from hip surgery and I invoked their daughter's name to get them to take a bath, it would be patronizing and insulting. The confused 92 year old where I work is a whole other story.

I work on a floor with many Alzheimer's residents, and I do occasionally tell "gentle lies". I make no apologies for that. If Mary says she just has to go home and fix her long dead husband supper, I might tell her he called and wants her to spend the night here. If she says she doesn't take any "[fill in the blank] pills" and she never heard of such a thing, I might tell her these are just her "bedtime pills" and leave it at that. If she were to know there were "blood pressure" pills or "water" pills she would flip out because every day it would be news to her and every day she would refuse because she "doesn't have high BP" and doesn't need any water pills.

For the love of Pete, would it be better for me to tell her her husband died ten years ago? Would it be better to tell her there's a "water pill" in the cup of pills SHES BEEN GETTING EVERY NIGHT FOR YEARS so she can have a nervous breakdown and refuse every cup of pills handed to her for the next two weeks??

I agree with Brandon that it is poor nursing when a resident says no to a shower or meds for days and you don't try to be creative. Usually there is a reason.. The CNA is rough or they don't feel like they have any privacy.. Sometimes they refuse meds because of side effects. You have to try, just not force.

I think Brandon is doing fine and most of the nurses here are hospital nurses who don't have clue about how LTC works or clearly have a personal axe to grind with the system.

Specializes in Transitional Nursing.

Yep, I totally love Brandon. Please, Please, Please prevent me from getting a bowel obstruction by telling me MOM is peppermint schnaps if I am demented and won't take it and its going to help me. I totally get what he is saying. Realistically, you can not go "by the book" in LTC. Honestly, I hope someone smothers me with a pillow once I am demented enough to refuse a shower. :(

The bottom line is this: if you are violating the residents right by lying and deceiving to deliver care you'd better hope that you don't get caught. And just because your demented residents act like children because of their disease doesn't mean you have the right to treat them as such.

And yes, falls are not 100% preventable but maybe if my Mom's nurses and aides had spent more time trying to prevent them instead of worrying about her not taking a bath and eating chocolates things might have turned out differently. She also had untreated cellulitus-the doctors and nurses at the facility had her wearing compression stockings because she had swollen legs. No one could understand why her legs were swollen. They also caused her problems with walking and the nurses knew this but did nothing to help her even though they admitted to CMS that she needed someone to help her walk. When she broke her hip the ER doc took one look at her leg and said she had cellulitis and gave her an antibiotic-it was cleared up before she left. She also had a raging UTI that the nursing home failed to diagnose.

So go on about bowel movements, failing to take showers and the other petty things you all are complaining about that your residents don't do. None of them is going to kill them.

And to Brandon-there is a difference between telling a lie to get someone to take medicine and not telling someone their husband died 10 years ago. You've seemed to have forgotten that your residents have RIGHTS which means the right to refuse medication and showers. That applies to the demented that you, by your own words, seem to use a lot of lies to make your job easier.

It's scary to thing that LTC and SNF hire people who coerce and bully residents into doing what they want them to. It's even scarier that people actually condone this behavior.

Specializes in Transitional Nursing.
Do it's better to lie and bully a patient into complying with your wishes? I hope no one catches on to what you are doing because you'll be out of a job if they do. Residents have rights-who cares how you feel about their behavior.

My Mom had one nurse that was bossy like this and she was yanked from the unit the minute I complained. No long after she was gone from the NH altogether.

Poochie-- If the resident has dementia and always refuses a shower, sometimes they DO need to be coerced into taking one. You can't simply say "Ok lets get in the shower". for one thing--they may at that moment think they are 7 years old again when showers didnt exist. You may have to take them into the bathroom, start the water and show them how it works to get them to say yes, and you aren't going to do that by saying "Mrs smith would you like to take a shower" You may very well need to say "Janice is coming to visit you tomorrow, don't you want to be clean for your visit"? Incontinent episodes are horrible on the skin--not to mention a bed bath would make the patient cold and if they truly don't want it they'll fight during the process. You can't allow someone who doesn't even know their own name to have feces stuck to their skin or to wreak of urine because their Peri area hasn't been washed. It is much easier on them (and us) if we can gently talk them into taking a shower. If they STILL refuse-well you try again later......

Whenever I did this I would be sure that the bathroom was all steamy before hand, that the shower chair they sat in wasn't directly under the water and I would talk to them or sing the whole way through. 9 times out of 10 the patient sleeps better that night and once the process is started they no longer seem to mind.

Most of us (caregivers) do not go into this field for the paycheck. Most of us love people and are here to take care of people. It isn't a power trip or because we love control that we try to convince patients to do things they don't want to, its because we honestly feel its good for them. The truth is, many patients who enter nursing homes get depressed and getting them to go play bingo with other people really does help them. Once i get to know someone and Its brought to my attention that they have always been a loner, I'll lay off. Not everyone benefits from that stuff but a lot of people do, and its evident in their behavior afterwards. No, I am not going to drag them kicking and screaming but I'm going to try more than just asking. If they refuse, they refuse. I pick and choose my battles. That being said, I can't allow a diabetic patient to eat an entire box of chocolates in one sitting so the nurse can cover them with a boat load of insulin. A few pieces, sure but in my opinion to allow them to over-do it is also abuse because they don't know any better.

SO, if I am able to talk my sweet little demented patient into taking a shower you bet I am going to do it, at least sometimes, because its better for them to get a quick warm shower than a cold bed bath and I don't want to go home at night knowing I've left someone un-clean with feces smeared all over them. (There is only so much a brief change can do) And not to be graphic---but with incontinent women especially loose BM goes places you can't even imagine---places that really require a good shower to get clean.....

I feel like its hard to understand when you aren't a caregiver, so I thought this explanation may help you understand why we would fib to a patient to do for them that which is only going to help them.

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