What are your personal standards when a patient "refuses care"

[DesiDani]

For example personal care and/or ADL care. Do you keep asking, find out why, or just leave it at that. No, I don't think that every patient who refuses care is mentally incompetent. They may just be angry, scared, or suspicious.

I do believe that when some healthcare workers and even Drs hear those magical words "patient refuses", that translates into never having to bother with that patient again. Hey after all, they refuse care and they have the right to refuse care. Yet I've seen patients who are like this and they are the ones who have 4 pressure sores, constantly on isolation, etc.

So do you just accept that a patient refuses care and when do you just give up and let it go?

[tinytrexarms]

admittedly I have resorted to bribery on many occasions. (Take your bath for me, there may be a soda in it for you) LTC is a different ball game though. I know which residents are fine with a 2X weekly bath, and who needs it 3X, and how to approach them, since I have them every day.

[0.adamantite]

For AAOx3 patients - I ask the patient why they are refusing and try to rectify the problem, reassure them, or provide education. For example if they are afraid to move due to pain I will set up a plan with them to administer pain medication prior to the movement, explain why moving around is important. I will say "Dr. Smith likes his patients to move" (patients seem to respect their doctors more than nurses sometimes). If the patient still refuses I will reaffirm their right to refuse but explain the consequences - "You will be at increase risk of blood clots, pneumonia, etc." I will then involve the charge RN and depending on the urgency of the situation I will notify the MD of the patient's refusal. Then I will document everything that I tried.

For confused patients - It depends, patient may need restraints or chemical sedation in order to provide safe care. For example confused patient won't swallow pills / spits them at me. Swinging fists at me when I get close to change their wet pad. I probably can't force them to swallow a pill but I can get an order for IV Haldol to see if it will calm the patient enough to allow cares, and then escalate from there.

[beautyandbrains]

Document, document & document. If they are refusing medically necessary treatment repetitively, you have to notify the MD.

[TheCommuter, BSN, RN]

I no longer work at the bedside as of this week. However, when I did work on the floor, I wouldn't pressure patients any further after a refusal. Since I dealt with high nurse/patient ratios and other time-sucking issues, refusals were at the bottom of my priority list.

Ain't nobody got time for that...

[hybr1d]

It varies from patient to patient. If the patient has all cognitive functions intact I try to reason with them and make a deal like alright we wont do it now but how about 5 o clock? It usually works. If they get violent or verbally abusive I dont bother, my safety comes first. Sometimes I call their next of kin and ask them to talk to them.

The ones with dementia are trickier, they will most likely percieve whatever I do as a violation if they dont want it done so sometimes I give them some oxazepam and come back later. First I send in another tech since it might just be a person thing though. When it is something that HAS to be done we are 2-3 people and do it with force which feels horrible, every time.

A difficult subject for sure!

[kbrn2002, ADN, RN]

Unfortunately my personal standards don't have much to do with it. We have a few we need to be fairly firm with to get them in the shower/tub but if the answer is still no, it is no. A resident has the right to refuse care regardless of their level of cognitive functioning and using restraints and/or force would be a one way ticket to the unemployment line possibly followed by a visit to the BON.

All we can do is document like crazy, get family involved if we are able to and last ditch effort the social worker and possibly the DON get involved. As NOADL's said in an earlier post, in LTC the regulations are daunting so refusal of cares is a bigger deal than it is in an acute care setting, especially if it becomes a pattern.

[hppygr8ful, ASN, RN, EMT-I]

For AAOx3 patients - I ask the patient why they are refusing and try to rectify the problem, reassure them, or provide education. For example if they are afraid to move due to pain I will set up a plan with them to administer pain medication prior to the movement, explain why moving around is important. I will say "Dr. Smith likes his patients to move" (patients seem to respect their doctors more than nurses sometimes). If the patient still refuses I will reaffirm their right to refuse but explain the consequences - "You will be at increase risk of blood clots, pneumonia, etc." I will then involve the charge RN and depending on the urgency of the situation I will notify the MD of the patient's refusal. Then I will document everything that I tried.

For confused patients - It depends, patient may need restraints or chemical sedation in order to provide safe care. For example confused patient won't swallow pills / spits them at me. Swinging fists at me when I get close to change their wet pad. I probably can't force them to swallow a pill but I can get an order for IV Haldol to see if it will calm the patient enough to allow cares, and then escalate from there.

You get to use Haldol! I am so envious in our long term facility we cannot use Haldol because of risk if "Sudden Cardiac Death" Now I come from an in-patient psych background and have never seen this side effect happen though it is often talked about. Still we can give any psych med without psychiatric justification and a we go round and round on the whole chemical restraint. I'm not sure how it is in other states but in California we are required to periodically wean people pf psych meds to see if they are still needed. It sometimes painful to watch the return of psychotic symptoms in previously stable patients.

Hppy

[LobotRN, BSN, RN]

I work(ed) acute care (Hey Commuter! Congrats) and my rule for refusals was this type of assessment and documentation:

"Pt refusing (shower/bedbath/pericare/turns). Pt assessed for (pain/disorientation-delirium/LOC/mentation, etc). Pt educated for rationale regarding (you stink to high heaven, and if you don't turn or bathe it ain't gettin' any better and prob a whole lot worse!). Pt stated "I know not turning or allowing you to clean me up means I can get an infection, but I don't want to!." Pt educated about options for timing and options of care (bed bath or hose down) and verbalizes understanding, continues with refusal. Plan of care adjusted to continue encouragement of compliance with ABC/xyz activity. (Other team members notified as necessary)."

Chart like a lawyer (parenthetical hyperboles in the prior example excluded, user results may vary and the described example is not typical of all clients. Use of the preceding example by any other party is with the understanding that no liability is assumed, express or otherwise, of LobotRN).

[imagenthings]

It depends. Some patients will not budge. I had patients who were raised not to bathe everyday so they will not wash the oils out of their skin. They did not use deodorant either because the chemicals were dangerous. The charge nurse used to send them to psych, but there would come back cleared. No psych issue. They were raised to bathe only once a month or when they were going someplace special. Just like some people were raised to take a shower morning and evening. We had to keep offering.

[MPKH, BSN, RN]

I leave it. I let the patient know the consequences of the refusal--for example: no recent set of vital signs=no pain meds--and will let them be. Patients have the right to refuse anything at any given time, and we can not force them to do anything (unless certified).

[canigraduate]

It depends on the patient and what they're refusing.

If the patient is a flaming a-hole, I run out of the room and sing "Tra-la-la!" Especially if refusing assessments. I always clarify, "I understand you're telling me to get out and not come back until morning, correct?" then go back an hour later, though, and try again. The second refusal for the night counts for the whole shift and I don't bother anymore after that. I give the hospitalist a courtesy call and let them know the patient is refusing care. I have yet to see a doc come and talk to the patient or discharge him/her, more's the pity.

If the patient is a little old lady who is confused and doesn't want to take her pills, then I hide them in a treat. If it's a confused little old lady who throws things and tries to bean me with her cane, I let her refuse then call the doc and get everything essential ordered as IM/IV until we can get some calming agents on board.

If the patient is A&O x 4, having cardiac symptoms, refuses nitro, pulls his IV out and tries to walk out, I educate, educate, educate all the way to the elevator while getting him to sign his AMA form and telling him to stop by the ER on the way out if he gets worse. (True story.)

If it's a little old guy with maggots on his open head wound, who stinks up the entire unit because of his nasty head and the piss and poop in his clothes, whose family is complicit, I go in and tell them that there have been complaints about the stench and the patient needs to take a bath NOW. "But, he just got comfortable!" "I understand that he doesn't want to move, but I have no choice. The smell is making the other patients and the staff barf." (Another true story.)

[sjalv]

Echoing what everyone else has said, 'it depends'. Working in the ICU, most of the refusals I encounter are a) people who do not want to wear their BiPAP, in which case I explain the risk of respiratory decline and the need for eventual intubation, b) people who do not want to be bathed at night and want to wait till the day, in which case I don't push the issue, and c) people who are delirious and do not want me to do anything (draw labs, take blood sugars, etc). In this case I really try to educate the patient and reorient them. I've had ethically concerning situations before where I have a patient like this and my coworkers tell me to just do what needs to be done anyway (e.g. take blood sugar because pt is on an insulin drip). I have to consider every situation like this individually whether or not the risk to the patient outweighs the harm of not following their wishes, because I don't think a clinical note of "Pt refuses blood sugar monitoring despite education regarding its necessity" when I have also charted "Disoriented x4" would hold up in court.