withholding medications ethical dilemma

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  1. Was this ethical nursing practice?

    • 5
      Yes
    • 31
      No
    • 13
      Grey area

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I have been a CNA for 5 years. i am also a nursing student (BSN/RN) on my last quarter. i work as a registry CNA right now, so i see a lot of different nurses and units etc.

I was on an ICU unit with a elderly female pt who was there for encephalopathy after trauma to the head. she fell outside a liquor store. she has history of alcohol abuse but she denies recent consumption. the liquor store owner states she regularly buys alcohol. she takes anxiolytics at home for anxiety. shes also on SSRI antidepressants. she has a history of chronic lower back pain, neck pain, and states she has pain all over.

I was called in to sit with the patient. when i came she was really agitated and anxious and kept trying to get out of bed. she is A/O X4. shes been there for 5 days now. she continuously asked for her pain and anxiety meds. she had, tylenol q4hr prn (mild to moderate pain 1-6) norco q4hr prn (sever pian 7-10), lorazepam q2hr agitation (on a scale CIWA scale 0.5-2g).

she knows her meds but doesnt know what times theyre suppposed to be given. she asked the nurse but the nurse refused to give her the times because she thought the patient was addicted and drug seeking. the nurse would say "thats all you care about is your painkillers to get off. you dont ask about anything else".

i was sitting with her the whole time and she was shaking and visible anxious the whole time. the nurse would refuse to give her lorazepam or pain meds until she was literally ready to get out of bed.

based on her CIWA she was suppsoed to get at least 0.5 to 1g q2hr however she only gave it twice the whole shift. at the beginning and at the end.

the mobile xray came. from her xrays i saw she had plates pins and other surgical metals in her neck. so that explains the neck pain.

the nurses excuse for withholding the pt meds was that her blood pressure was too low and her respirations were too low. her blood pressure and respiration would naturally lower when she fell asleep but shot up to normal when she was awake. so the pt is anxious so is constantly looking at the clock, so i advised her to relax and try to sleep so that the time passes faster. now, the nurse comes in to assess the patient but every time she would come, the patient was napping. the nurse would write down pt's v/s and leave. then the pt would wake up and ask for her meds and anxiolytics. the nurse would come in and say that her v/s are too low even though they arent when shes awake. so this goes on for the whole shift. i told the nurse that shes axious and in pain but the nurse just shrugs it off and says shes an alcoholic, all she wants to do is get high.

this RN was floating from another unit to the ICU. shes from a medsurg floor.

in my head this is not ethical practice. is it? pain and anxiety are subjective. sometimes objective data can help us assess a patient's pain or anxiety but the patient's word should be taken as truth when it comes to pain or other subjective data. or at least thats what our nursing school teaches us. im always learning so please do provide constructive criticism thanks!

Thank you for any feedback!

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Nurse wrong, willthemurse right

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Specializes in Cardiac Stepdown, PCU.

Theres a whole lot of all of wrong with this.

A medsurg nurse in the ICU? Only critical care certified (AACNs ECCO, not necessarily CCRN or PCRN) can go to the icu in our facility. If we have to pull someone from PCU/stepdown then that medsurg goes to pcu and takes non critical patients.

This situation can't be corrected now, but next time... Speak with the icu charge nurse, unit manager, another nurse... Anyone, and share your concern. Make a fuss. Stand in the doorway and protest loudly the patient needs reassessment. Have current vitals in hand. I'm assuming you took the patients vitals while agitated, as you knew they were risen at that time vs from when she was asleep. And really her vitals are important to consider when giving meds. She could be 120/80 awake and agitated but if she 98/68 while sleeping how much further will that ativan and Norco drop her? Especially if they are given close to one another. That aside, the nurse was completely wrong in how she acted with that patient and the way she spoke to her. Always speak up if you think somethung is wrong or someone is being treated unfairly or wrong by their nurse. I don't care if your an aide, the custodian, a lab tech... Whomever. Say something.

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This sounds like a difficult situation. If the patient's vital signs were too low when the nurse assessed her, then that is a valid reason for holding them. However, if the nurse was simply holding them because she thought the patient was a drug addict, then that nurse is, indeed, wrong. And based on what you were saying, it seems like the latter is the most true. Why would that nurse first hold them if she thought the patient was a drug seeker, and then later change her excuse to low vital signs, if those vital signs were the true reason for holding those medications? The nurse's comment to the patient that you quoted also indicates to me that this nurse wasn't holding these medications for the benefit of the patient. Her response almost seems abusive in a way. And based on what you described, it sounds like this patient had plenty of reasons to need pain medication. Although I obviously wasn't there, I believe that this nurse was in the wrong. Please report this behavior to someone (your manager, that nurse's manager, etc) so this nurse's behavior can be addressed.

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Was the nurse assessing CIWA every hour? Were there other signs besides the anxiety? Was she hallucinating, sweaty, was she shaking?

The purpose of Ativan with a CIWA is to prevent DTs. You have to score s certain amount to be able to get the Ativan and there's about 10 different things you assess.

If this patient is on scheduled pain meds and anxiety meds at home, they should be scheduled in the hospital. That needed to be addressed by the nurse.

I don't know why a medsurg nurse was floated to ICU. That can be dangerous. Any floor nurses that we hire on our unit still go through an orientation because things are very different.

Maybe this nurse just needed some education. Unfortunately, I'm this day and age of the "opioid crisis" people with chronic pain get labeled as drug seeking and some nurses find it appropriate to withhold meds.

Even the drug addict can experience pain.

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I usually feel like im walking on egg shells and have no say on anything because im registry. they just look at me like (how do you know ur just a registry cna). ive spoken up before but i ended up getting DNR'ed (do not return) even though i did nothing wrong. they might do an internal investigate but they wont un-DNR registry personnel. at least not me. so i usually just say yes mam and continue to do my work as competent as i can. i need to pay for school, rent, and my bills so getting DNRed is not in the equation for me. i dont encounter situations like this often. usually nurses are more competent than that.

they were trying to send me home too because the pt had not gotten up all day... well maybe because i was there calming her down and holding her hand reassuring her and distracting her. they were also trying to downgrade her to a lower acuity since she was mostly on PO meds now.

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I don't blame you about having to keep your mouth shut. Unless someone's life is in danger.

You're learning how to be a good nurse. How to treat CNA's even from registry, and what hospitals to not work in.

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Specializes in Pedi.

I would want to hear the nurse's point of view before I make any judgment as I know, when I was working as an aide and was in nursing school, I sometimes sat with patients and had no idea of the whole picture.

Also, I can assure you, that there is no way the patient was supposed to get 0.5-1 GRAM of lorazepam, ever. And q 2 hr seems like a crazy frequency, q 6hr is a normal frequency for lorazepam so the fact that she gave it twice in 12 hours seems relatively normal to me.

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I would want to hear the nurse's point of view before I make any judgment as I know, when I was working as an aide and was in nursing school, I sometimes sat with patients and had no idea of the whole picture.

Also, I can assure you, that there is no way the patient was supposed to get 0.5-1 GRAM of lorazepam, ever. And q 2 hr seems like a crazy frequency, q 6hr is a normal frequency for lorazepam so the fact that she gave it twice in 12 hours seems relatively normal to me.

On a CIWA scale, it's ordered every hour. If the patient was sleeping each time she went in, which should have been every hour, then no Ativan would have been necessary as the patient would probably not have met the criteria for Ativan unless they were having certain symptoms.

Our CIWA has orders for a score of 12-20 they get 1mg, greater than 20, its 2 mg. If a nurse gives more than I think 20mg in a 24 hour period, we switch to a drip.

I think that's why home meds should have been taken into consideration. They were not only looking at alcohol withdrawal, but benzo abs narcotic withdrawal.

The ICU is not the place to try and detox a person. They are already very sick if they are in the icu. The stress of detoxing will make the underlying illness worse.

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Specializes in Surgical, quality,management.
On a CIWA scale, it's ordered every hour. If the patient was sleeping each time she went in, which should have been every hour, then no Ativan would have been necessary as the patient would probably not have met the criteria for Ativan unless they were having certain symptoms.

Our CIWA has orders for a score of 12-20 they get 1mg, greater than 20, its 2 mg. If a nurse gives more than I think 20mg in a 24 hour period, we switch to a drip.

I think that's why home meds should have been taken into consideration. They were not only looking at alcohol withdrawal, but benzo abs narcotic withdrawal.

The ICU is not the place to try and detox a person. They are already very sick if they are in the icu. The stress of detoxing will make the underlying illness worse.

Thank you!! Someone who understands detox and withdrawal. So many nurses seem to think that they need to ration doses and prevent "addiction". The problem is that the patient already has an addiction to another substance and needs to be detoxed from that for thier safety but the side effects can be fatal therefore reducing the physiology stress on the body is essential.

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Specializes in Emergency, Telemetry, Transplant.
Also, I can assure you, that there is no way the patient was supposed to get 0.5-1 GRAM of lorazepam, ever.

I totally missed this, but maybe it was a typo in the OP.

However, there are a bunch of other things really don't seem to make much sense. How does the sitter know that the liquor store owner said that the pt often comes in to buy liquor? How does the sitter know the home meds? How does the sitter know what the PRN Ativan orders are? How does the sitter know why the RN is withholding the meds? My biggest question: why is a medsurg nurse being floated to the ICU to take care of a critically ill patient?

Maybe there are perfectly reasonable explanations for all of this, and I invite the OP to come back and explain these.

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Specializes in Psych, Addictions, SOL (Student of Life).

Here here - You have learned what kind of nurse you don't want to be! Remember you are the patient's advocate?

Hppy

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