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]

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.)

ahhh.....definetely wrong to do this......for this patient.......he has so little control....this is a way to have some.....good luck

[animal1993]

Morte--

I think that is what bothers me the most. (For him, as well as the other residents.) I realize that there are only so many hours in a day, but I watch nurses, CNA's, and other staff rush around trying to force these people to do things as quickly as possible just so they can take a break, etc. (Not that I'm saying that all staff is this way.) I think a lot of times people forget that these residents used to be functioning members of society, and now they're literally prisoners in their own minds and bodies. I have seen it happen too many times, already, where someone will try to essentially bully a resident into complying, and are met with resistance. Yet, when this same resident is treated with respect, and you actually ASK them to do something for you, they usually are more than happy to oblige.

It made me sad that our clinical instructor didn't use the meds situation as a learning opportunity for us.

[fiveofpeep]

hmm. what if the MS patient is refusing meds because he wishes to die naturally of the complications, rather than prolong the suffering?

If that is the case I find that very wrong to hide his meds. I agree with the others regarding incompetent patients, but definitely with competent patients: this is lying and wrong

[pennyaline]

hmm. what if the MS patient is refusing meds because he wishes to die naturally of the complications, rather than prolong the suffering?

If that is the case I find that very wrong to hide his meds. I agree with the others regarding incompetent patients, but definitely with competent patients: this is lying and wrong

Please consider too the cognitive impairments that often accompany MS. Sometimes, their reasoning and judgment is seriously effected by their disease.

At my facility, most residents with poor or fluctuating cognitive abilities have orders from their physicians specifying that meds can be put into food or applesauce if necessary. At that point, it is up to the nurse giving the meds to decide. Some residents swallow their meds better if they are put in food or applesauce, too.

[animal1993]

I'm not sure if this resident has a physician's order in place for med refusals, and neither was my clinical instructor or the student in question. My problem is that neither one of them bothered to check with a staff nurse (or even the patient's chart) before hiding his meds in his food after he made it perfectly clear that he didn't want them.

[2BSure]

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.

That is quite an inaccurate statement. Scary even.

[cursedandblessed]

we had a similar situation last week, called the doc and was told to call the family member(poa). once the family came patient took their meds right away. a manipulation to get the family to visit the elderly patient, possibly, but the patient's bp had increased to well above reportable criteria by that time.

if a patient refuses they must be told the possible repercussions to their health by refusing the meds, which mine was. that is our policy, sometimes once it's explained they will take it, sometimes they don't.

it's not just meds, patients can refuse a bath whether they smell yuckky or not. (sorry just had to throw that in there, i always end up with the elderly who don't want a bath/perianal care, usually it's because they've had people who don't keep them covered.)

[EricJRN, MSN, RN]

Used to run into these issues all the time in the prehospital setting. An alarming number of providers (prehospital and beyond) think of consent for treatment/transport as an all-or-none concept.

I've heard medics tell MVA patients, "I can't take you to the hospital unless you go with this collar and on this board." I also remember multiple instances of patients being told that they couldn't refuse transport after being given a drug (in our system usually D50W or adenosine).

It makes me want to ask these providers whether they truly believe they're correct - or whether they just think that these statements will bring about compliance, truth or not.

[Valerie Salva, BSN, RN]

My mil teaches nursing law and ethics at a university and for the state where she lives.

She uses an example in her class of an actual case where a nurse was disciplined by her state BON, and was sued (and lost). An A&O pt refused his meds. The nurse hid the crushed meds in the pt's food, and the pt got his meds without knowing it. The nurse told the pt what she had done. The pt complained to the facility (A psych hospital) and the nurse was reported to the BON. The BON stated that the nurse had committed assault by tricking the pt into taking his meds against his will. Also, the pt sued her and won.

[dianajh73]

I have to say I think that being reported to the BON is exactly what should happen. I'm surprised by how many find this as common practice. I have frequently used applesauce to make pills palatable or help people who have difficulty swallowing water, NEVER when a patient refused. It seems like there should be other options although I know these are very challenging situations. Frequently it takes an attitude adjustment for the caregiver as much as the pt.

In the situation OP described it seems there was no excuse for either the student or the instructor. Even if instructor agreed with action I would have expected more reaction just for doing something like that without clearing it first. With your kid it's creative but with pt it is assault and illegal.

[pyrazen]

"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.)"

I think this statement is the answer. This pt had the right to refuse. The student could have gained compliance simply by waiting or having someone else give the meds.

[angel_bear_4670]

I am an EEN in Australia, I have worked in Aged Care (Dementia) and am currently in the Hospital system. My son has mental health issues and requires medication to remain stable .. he lives away from home and has been institutionalised on the odd occassion.

As a nurse, I can usually get a dementia pt to take their med's. At times, we have hidden the medication, but ONLY with families permission. It takes 10 minutes to make a phone call, not usually a life and death situation with regular medications. The Nursing Home usually get's family to sign a form when the resident is being admitted. That's for a dementia patient.

For a regular Nursing Home patient who is A & O, they too sign an agreement, saying *(loosely) they will do what the nursing staff recommend **...blah...blah...blah ** .........the nurses backside is thereby *covered*. Then there is ME. I have told my kids, when I am ready for a Nursing Home, I want ALL medications ceased so I may die a natural death sooner rather than later (....cause I sure as heck don't want to be one of those bed-bound miserable souls stuck in a personal hell -- thankyou very much ..) I look forward to the battle with the Care Nurse Coordinator over THAT debate! (the less tablets they give out, the less funding they get for that patient .. they won't like me .. ha ha) I'm like the MS guy, I want control of something as my world implodes around me.

And then there is my son, who, at 18, is A & O and of *reasonably* sound mind who needs his medications regularly and who, for some odd reason, had a bit of a melt-down and defied the nursing staff, who then, WITHOUT my permission (as his mother and this was before he turned 18 which is an adult in our country) held him down and gave him IMI's of some anti psychotic meds to simply make him *STOP* (the 2nd one worked) because we have a ZERO tolerance level of being abused by patients and the law cover's our butts (mostly) in those circumstances. He has since learnt that taking those 2 little tabs at night are much better than being held down and *stabbed*.

The *books* give you information, but life skills gives you skills. We, as nurses, have a duty of care to our patients/charges and it's how we interpret our duty of care. Of course, before anything else is done, I would double check with a senior nurse, give my reasons and discuss the issues before I took it upon myself, I have had this debate before with an RN who wanted to sedate my demented patient and I felt it unnecessary as long as he could wander and we kept our distance. My tact worked, he tired himself out quicker and went to bed like a kitten with no drama's.