Was this ethical?

[animal1993]

I overheard a fellow student talking to our clinical instructor about whether or not a certain patient had ever taken his meds. (He is notorious for refusing them.) When our instructor asked about it, the student told her that he had refused them again at lunchtime, but that she went ahead and put them in his pudding and fed them to him with his lunch. My instructor seemed pleased with her response, but it seemed unethical to me. It is very frustrating when patients continuously refuse their medications, as they certainly feel better when they stay on schedule, but isn't it ultimately the patient's right to refuse them without having to worry about someone "sneaking" them into their food?

[morte, LPN, LVN]

to do this you would need an incompetent patient and a doctors order.....not simply a recalcitrant patient

[Daytonite, BSN, RN]

Did the patient have dementia? You also have to consider that the very fact that being a patient and being present in the facility for care is consent to treat.

[mama_d, BSN, RN]

I agree, it depends on the situation.

I'm assuming that the patient was demented or at least had acute mental status changes since he had to be fed, and therefore unable to be competent to make the decision to take or not take the meds. If it was a pediatric patient, who was developmentally unable to make the same decision, would you still feel there was an ethical dilemma? Just food for thought.

Now, if the patient was a&o, that's a different story....

[caliotter3]

I wouldn't sneak medication to a patient who was alert and oriented. Their reason for refusal might be much more than just personal preference or being a PITA. It is their right to refuse if they are competent to do so. There are ramifications to one nurse providing meds and the next three doses being missed. And how can you track their condition properly if they are only getting their meds here and there? Lots of things to consider when making a decision to do something like this. Refusal should be discussed with the MD and with the patient to get to the bottom of it and provide appropriate continuity of care.

[elkpark]

Every client, in any setting, has the right, under state and federal rules & regs, to refuse any medication or other treatment, unless s/he is incompetent and, in that case, the right is held by the guardian or POA. In the case of minors, the parent(s) or guardian has the right to give or withhold consent. In my specialty area, psych, every state has a legal mechanism (the procedures vary somewhat from state to state) for forcing psych meds on seriously mentally ill clients who are refusing treatment but are not acutely dangerous, but the process is usually fairly complicated and requires a fair amount of documentation. I have found over the years, though, that providers in med-surg settings are more likely to play "fast and loose" with the rules and laws than psych providers.

Signing an admission "consent to treat" form and being present in a facility is not blanket consent to have meds forced on you against your will or without your knowledge.

Unless the specific client (in the OP) has a duly authorized guardian or POA who has given consent for the medications, slipping the medication into food unbeknownst to the client is illegal and unethical. I'm surprised that the clinical instructor didn't raise these issues with the students.

[JomoNurse]

nurses "sneak" medication to demented patients all of the time. they are demented. they are unable to make decisions that are best for them. often times we put the pills in apple sauce or something simliar and encourage them to eat the apple sauce, which they usually end up doing. a lot of the time you feel like you're working with young children as often this is the type of mentality these types of patients have.

if a person of sound mind and judgement refuses the medication, then we don't give it.

[elkpark]

Just because nurses do something "all of the time," that doesn't mean it's legal or ethical. If there's a guardian or POA who has given consent, that's one thing. If not, what you're describing is, legally, assault. The fact that no one is going to bring charges doesn't change that.

I realize that nurses who work with demented clients are often put in a bind -- the client is obviously unable to make reasonable decisions, but family has not taken steps to get someone appointed guardian, or there is no POA named earlier by the client. If family is not available or willing to "step up," facilities can go to court and get a guardian appointed -- that is the most appropriate way to deal with these situations (I have a lot of experience doing competency evals in acute care settings for exactly this reason -- so the hospital can go to court and request a guardian be appointed).

[JomoNurse]

I guess this all goes back to "book nursing" vs. "real nursing". I remember when I first started out as a new nurse a patient (with dementia) was to go an undergo procedure (don't remember which) and as part of the procedure, a pre-op PO med was to be given. Well, I went in there, and the patient said "NO! I don't want any medication! You're trying to kill me!". So I didn't give the medication. A few hours later my boss came to me and said "Did so and so get that medication?" I said no and explained why I didn't give it. Her eyes opened wide and she said "she HAS to have that medication, go grab the applesauce and give it right now." So I did and the patient took it.

As a nurse in med-surg, you'll probably run into a fair amount of dementia patients. You have to get "creative" and give the medication. There's no time to have the hospital go to court and have a guardian appointed. That's not realistic nursing for a short 3 day hospital stay. Having a guardian for the patient isn't going to change the patient's mind to take the medication, either. You'll still have to hide it in applesauce.

It's been a while since I've been in school, but from what I know, hiding a pill in applesauce for a patient that is NOT of sound mind of judgement isn't really "assault" that would hold up in a court.

Anyway, this is getting too long. Nursing school is very different from the real world.

[animal1993]

Thank you all so much for your replies. You've all brought up some interesting points. I probably should have been a little more specific in my OP. The patient in question is not a dementia patient. He has MS; that is why he needs assistance with feedings. As I said before, he is notorious for refusing his meds, but will usually consent at some point during our time there. (I think it depends on who is trying to give them to him, and with what kind of attitude.)

[Nurse523]

Well, there are some questions that needs to be addressed.

1. Is this pt competent to make his/her own decisions?

2. Is this pt just like that and this is the daily routine?

3. What type of medication is it?

4. Is it okay to mix the medication with the food?

I see this a lot in long-term facilities (geriatrics settings). Since a great portion of seniors can have dementia of some sort, cannot feed themselves or they are stubborn.

What type of medication was it? If it is something like a depression medication which takes pretty much a month to work, it would impact the pt's quality of life and the workload on the other nurses (if the pt had severe depression and often tried to harm himself/herself).

Was it okay to mix the medication in the food? Would the medication even work?

[Nurse523]

Ahh! That makes so much sense! Well, I think someone should sit down and discuss about the issue. Someone should speculate why he does not want to take medications, talk about other medication options, assess values and beliefs and the pros and cons of not taking medications and make sure that the pt clearly understands this discussion.