What can we deny our patients?

[Crux1024]

Question here, Inpatient hospital setting.

What can we deny pts? Like with a diabetic patient insisting on regular soda and not diet, or asking for 5 apple juices with each meal and a BS of 300 already? Pt on fluid restriction sticking his face under the faucet (to drink)?

Where do we draw the line? I once had a pt insist on something that he shouldnt have had and a preceptor gave it to them, saying we cant deny them what they want, even if it interferes in medical care.

Another example: I had a dialysis pt ordered to be NPO by a surgeon for an I&D to take place AFTER dialysis. Pt heard this and had a fit, was refusing the surgery and dialysis unless he had something to eat before hand. He really needed dialysis, and after discussing it with some other nurses (including the dialysis nurse I called report to), I gave him some cereal so his dialysis wasnt delayed. I then called the surgeon to inform him and he had a fit, telling me had to be NPO and how dare I feed him, even after I explained. I was very conflicted with this one. I feel that I shouldnt have fed him in anticipation of surgery, but if I didnt, he wasnt going to comply with ANY care that day. IDK.

Where is the line?

Any opinions are appreciated!!

[Murse901, MSN, RN]

As long as the patient is competent, you can't deny him/her any reasonable request, even if it conflicts with their plan of care. All you can do is patient teaching, then if the patient continues to refuse to follow the plan of care, document, document, document and notify the attending of the patient's refusal. Eventually, the patient will be AMA'd.

[Altra, BSN, RN]

You are providing a plan of care. A competent patient has the right to refuse the plan of care, but that is not the same thing as you delivering/providing/enabling something that directly conflicts with the plan of care.

Some concrete examples:

I would not give a diabetic patient regular soda. However, I will also not tackle the family member who brings it to the patient. Document, reiterate the rationale, and make sure the MD is aware.

Feeding the preop patient? Nope. The patient can of course refuse the planned surgical procedure.

I hope this helps at least a little -- differentiating between appropriately individualizing care for each patient vs. doing things that completely derail the plan of care.

[leslie :-D]

often we have decisions to make and nsg judgment, md orders, ethics, or threats, can create oppositional conflicts.

i wouldn't have given a sugar drink, for i will not enable destructive behaviors.

if a family member brings it in, i tell them pt should not be having that, and let them decide.

(document meticulously)

and i would not have fed dialysis patient.

strict orders for npo.

a zillion more pts will try to manipulate you this way.

when it comes to our pts, they can be extremely complex with their needs, wants, expectations.

experience should teach you astute nsg judgment, that will enable you to meet all their needs and even some of their "wants".

you're doing fine.

wishing you the very best.

leslie

[oramar]

You know I have actually been asked by patients to pick them up a pack of cigs. Naturally my answer was in the negative range.

[GeauxNursing]

great question and great responses so far!

[Crux1024]

Ive never given a diabetic patient the sugars drinks or the excessive apple juice they wanted, I also didnt give the fluid restricive pt anymore to drink, asked him to stop putting his face under the faucet and explained the need for fluid restrictions..But the dialysis pt, im still stuck on. In all cases, teaching was performed and appropriately documented.

Every nurse on my floor (3 others) plus the one I called report to were of the mind to feed the dialysis pt, otherwise he wasnt going anywhere that day. Its a tough call. Im still conflicted though you all make very valid points. I did go directly against a doctors order. Ugh..It only gets harder from here, huh? LOL (been in only 6 months..)

[PostOpPrincess, BSN, RN]

You are not the parent of a patient. You are a person in charge of the plan of care.

Do NOT enable these people.

Just the facts ma'am and if they can't comply, that is THEIR problem not yours.

Do NOT make it YOUR problem.

You were very wrong in feeding that patient without checking with the surgeon. If he didn't want the surgery nor the dialyses because he wasn't going to be fed, SO WHAT? That's his choice and you need to be clear about that. Draw the boundaries.

Again, YOU are not a parent. You are a professional summarizing the choices a competent patient can make. Don't make THEIR problem YOUR problem.

If they don't like it, they can leave the hospital.

[Higgs]

Well said previous poster.

If they don't like how we do care - even after we've explained why, they can go and find a hospital that will let them do what they fancy.

It's not a prison, they can leave whenever they want.

[blondy2061h, MSN, RN]

I can totally see giving the preop patient cereal if they would likely die from refusing dialysis without it. I often don't get why we keep people NPO so long, though. Surgery at 1500? NPO after midnight. Surgery at 0600? NPH after MN. One person is NPO for 15 hours, the other 6. How is that reasonable? Often I think we'd get better patient compliance if we were more reasonable.

As for diabetes and sugared drinks, what if the BG was normal when they requested it? What if the patient had a history of consistently good glucoses on their current treatment. Then would you allow it? I'm seeing a few I'd NEVER allow that comments, but again, more reasonable may offer better outcomes.

[AngelfireRN, MSN, RN, APRN]

We have had maintenance come in and turn the water line to the sink off before, for patients on fluid restriction that were using the sink for a watering trough. I have been known to intercept pizza delivery for an NPO patient, and hold it at the desk for his family to retrieve, only to snatch it right back when they headed to his room with it, with every intention of feeding him. The doc was right behind me, I just beat him to the grab.

I am their care provider, not their Mommy. I followed the docs orders, and now I expect the floor staff to follow mine. I would be highly peeved if someone deliberately fed a manipulative patient because they were having a pouty fit. Inform the doc what the patient is saying/doing, and let it rest with him. All the colleagues.preceptor backing in the world will not protect you if it's YOU that goes against an order.

My patients know that, once they buck the care plan, barring a REALLY good reason, they will be discharged from my care and that will be the end of it. I am there to take care of them and help them, and hold their hand if need be, but once you start refusing treatments and meds because you think you know better, you can fend for yourself. Noncompliant patients are just too much of a liability to my licence, as they are usually the first ones that will sue you when something goes wrong. Always, ALWAYS document thoroughly. It's your best friend.

That being said, you're new, and I remember those days. You'll do fine, but don't let the patients walk on you. You'll be marked as a doormat from the word go. Good luck to you, honey. As I said before, you'll be fine.

[E.R. Rookie]

They can do whatever they want but Im not going to enable them. Some patients are just stubborn/irrational and no patient teaching will help.

Personally I would not have fed the patient due to being ordered not to. Either way it was a catch 22, so I would have stuck to the DRs order.