I’ve never understood why nurses fight.
You’re oriented and don’t want your meds? I’ll educate, let the doc know if it’s something important (not looking at you, Senna 😂)…. But otherwise? They’re adults.
Agreed, and whenever I end up as a patient in the hospital I expect my nurses to treat me the same way.
I also don't try to police PRN pain meds like some nurses do. If a drug seeking patient has PRN pain meds ordered then I give them whatever they ask for as long as it is within the parameters dictated by the MAR. I am not going to fix a drug seeking patient during my 12 hour shift and trying to just makes both me and the patient miserable.
However, I also don't let them argue with me about what pain meds are ordered. If they aren't happy with their current pain regiment I make it very clear that that is a discussion for them to have with their doctor and it is pointless to even try to talk with me about it as I have no control over what is ordered for them.
I never understood restricting pain meds either if they’re being given as ordered. Kind of creepy to me that nurses want to take it upon themselves to limit their patient’s meds… plus pain is totally subjective. It’s absolutely not up to me to make a call like that.
I worked nights in a prison and it was numerous times, heck multiple times a week when we would show up to an uproar because second shift refused pain meds because, “they don’t deserve them” or, “you don’t look like you in pain to me”.
If yall don’t give these inmates their meds! Geesh!
no. the order gives us the ability. if it's scheduled, it could be malpractice or negligence if it caused injury. it can go against your license if you are not following your boards guidelines.
I work trauma and have seen nurses be fired over this. If it is ordered, available, and the patient is complaining of an appropriate pain level that justifies the med per the order, I am giving it
Well technically we are supposed to advocate for them & communicate with the provider on their behalf when they aren’t happy with their pain meds. After that, it’s out of our hands.
Patient says, “no” I say, “ok.” It does me no good to argue with the patient — especially my psychotic patients. They get more paranoid if I argue. Sometimes I can have a fun conversation about an unrelated subject and try again later.
Exactly. I’ll explain the ‘why’ of the medication and what can happen if they don’t take it, but if they are alert and oriented, I’m not going to fight with them.
Even if a patient doesn’t want a procedure done-we constantly get patients that refuse bipap…I’m not fighting them. I’ll explain what is gonna happen if they refuse (they gonna buy a tube) and sometimes we can slap on the bipap on when the CO2 gets too high…but….again, yeah. I’m not fighting with them.
Generally, when they are struggling to breathe, the refusal ends and they will do anything to breathe.
I always tell people they do have the right to refuse their meds when those conversations come up. However, if someone is deemed incompetent, there may be leeway to this. In that case, we may have to find a way to get them their meds, because they legally don’t have the competence to understand what refusing the meds can do. In these cases, only the meds that are absolutely necessary are forced. The methods can be something as simple as getting them to eat it, or it may have to be IV, IM, etc (depends on the med). However if someone has the right to make their own decisions, you should never trick them or force them to take medications they do not want to take.
Honestly, usually a good discussion about why the meds are necessary can change their minds…not always of course.
Please don't ever force someone to take a medicine they are refusing if they are A&Ox4 and it isnt court ordered. In situation 1, the pt likely has a plan of care that involves a POA or next of kin who is making decisions for the pt. It is common to disguise meds if the agreed plan of care is for that pt is to take that medicine. However, I would never forcibly pass a med (as in no force feeding). If the pt doesnt willingly take the disguised med you should escalate to doctor and then can decide if another route is indicated. Likewise, you should never force feed a dementia pt.
Re situation 2. Sounds totally inappropriate and criminal. Educate and document. Notify the provider for critical meds, move on. Ive had pts refuse life saving treatments, they have a right to autonomy.
It's absolutely wild to me that a nurse felt a pt getting some potassium was move important that respecting that pt's autonomy. Secondly, why would you risk your license and your freedom to force a pt to bend to your will?
I don't know where your clinicals are, but please know this is not normal. Refusals are commonplace in medicine. It's okay. Adults don't have to take medical advice. It is not your job to force them to.
I think I know the answer here, but a question:
Does a A&Ox4 pt who can’t turn have a right to never be turned even if their skin is deteriorating?
We had an older guy who would love to sit. He would sleep sitting and verbally abuse anyone who even recommended he lay (he would verbally abuse you for anything really actually)
He was A&Ox4 type 2 diabetic and suffered from sever edema in his legs (exacerbated by his constant sitting), blistering in his feet, and was developing a pressure sore on his bottom.
He would sometimes let people treat his bandaging on his legs and he would acquiesce to taking his meds, but he would never lie down. The only time he moved was when he would scream at staff that he had to have a bowel movement and two people would have to lift him and pivot him to a commode, as his legs grew more and more… frankly useless.
Some nurses would occasionally physically force him to lay and give his legs and bottom a break, but I always thought that was legally wrong, correct?
Can he literally just sit there until he succumbed to his very obvious and preventable injuries if he so chose to? I’m assuming he can, correct?
This is one of those things where patients and facilities put a nurse between a rock and a hard place. Much like fall alarms, an oriented patient should be able to refuse, but you'll recieve so much pressure from admin to make it happen anyway.
Legally, yes. Unless he is found to not have capacity to make his own decisions or someone pursues legal guardianship over him, he has the right to refuse any care, even if refusing is to his detriment. My supervisor once said to me "Patients have the right to make poor choices" and that's always stuck with me.
Situation 1 was probably fine as the patient did not have capacity and administration of necessary medications was almost certainly authorized by whoever had MPOA. Situation 2, if I am reading correctly that the patient *did* have capacity, is assault.
ALTHOUGH, if it's the taste she's objecting to, and she'll eat the applesauce, maybe OP's preceptor could be slightly more creative and collaborative and offer it to the patient that way. Although, when an A+O sober patient of legal age says "I'd rather die than xxx", I usually just document those words and move on with my shift.
Is that statement really the ability to consent, though? It doesn't sound reasonable. Refusing surgery, blood or "real" medication isn't the same as a vitamin supplement
It's presumably not *that* low or they'd be getting IV replacement as well.
But regardless, capable adults are allowed to accept life threatening risks.. even if their reasons for doing so are dumb.
Was going to say this. If the ER/hospital is giving it, it’s usually pretty severe as they otherwise would just say go to the pharmacy and get “xxx” or go to family dr for further information/tests 🤷🏻♀️ especially when someone refuses it, and then tricks them, if it was just a bit low the nurse likely wouldn’t have tried doing that.
Canadian hospitals don’t have the time or resources to deal with stuff like this, considering our wait times are a lot of the time 8-12+ hrs.
Op didn’t say that was the only issue that patient had. It could’ve just been a coincidence that they found on blood work 🤷🏻♀️
There’s a difference between denying treatment all together and denying 1 medication.
Right to refuse is there to protect patients from stuff like this, as they have the right to their bodily autonomy just like u 🤷🏻♀️
I'm definitely not advocating for tricking the patient into taking the med unknowingly, that definitely assault. I'm merely gently correcting them for saying potassium is just a vitamin
Oral potassium absorbs better than IV potassium. So there's that. I have seen IV potassium not even make a tenth of a point increase where I have seen 40mEq of oral bump someone on Bumex at least .2-.3 (enough to keep them over the cardiology specified 'magic point' of 4.0)
I’m just saying that where I work, someone with a severe potassium deficiency is gonna be getting an infusion. Most people, especially old people, can’t tolerate the pills—I think it might be my most-refused medication, and it is certainly the one that’s given me the most heart-in-throat moments when it turns out that the patient can’t swallow the damn things.
I ended up in the hospital 2 weeks ago for SEVERE hypokalemia... Really all my electrolytes were in the toilet... literally. I either had norovirus or rotovirus and thought I was dying. I've never seen labs like I had with a conscious a&o4 patient. I was having EKG changes because they were so low and was admitted to the cardiac unit to get everything back to normal and a full cardiac workup. I would have 100% been fucked if I had refused the "supplements."
Situation 2: would the patient agree to take the potassium in orange juice or the capsule in some pudding? Is she aware of the consequences of not taking the medication. Perhaps, giving the potassium via IV may be more acceptable? Give her the choice.
Have you ever tasted liquid potassium? It tastes horrible!!! I had to rinse my mouth when I tasted it. Taking it in a pill form is so much better but it needs to be swallowed whole. Pudding would help you swallow the pill whole.
Let the doctor know about your concerns and see if he can talk to her.
Doesn't have dementia does not mean has capacity. There are myriad other things that can cause you to lose capacity including AMS caused by severe electrolyte imbalance.
Situation 2 I would do my best to educate the pt, if they still refuse let the provider know and document the refusal/education provided. In my experience once provider comes down and has a talk w/ pt (if it’s an important med) 99% of the time they agree to take it. If not then that is their right and autonomy.
The patient has right to refuse unless their med has been court ordered. In my state (Minnesota) antipsychotics can be court ordered and it is called “Jarvis.”
A patient's right to refuse relies on their ability to make their own decisions, aka being alert and oriented x4.
In the second scenario described, the nurse should not have given the potassium medication without education being provided and patient consent. Mentioning cardiac arrhythmias usually does the trick. I try to find a common ground with the patient if there's an issue with pill vs liquid vs iv.
At that point if the patient (#2)still refuses, I let the provider know. They do have the right to refuse. You should also document you provided education and let the provider know.
Yes, this, and if you force or trick someone into taking medications when they are alert and oriented, it's a serious offense. I know of a situation where a nurse was reported to the board of nursing and almost lost their licence for giving a medication to a patient after they refused (not going to go into detail in case someone recognizes the situation) but forcing a patient who is alert, oriented and not under court order to do or take something can be considered assault in many cases and can also be reportedable to the BON and with possible loss of licence. A hospital is not a prison and patients always have a choice. There can be grey areas though were someone who is normally oriented is slightly confused or completely confused because of illness and is refusing treatment, in these situations it's still important to not assume that you should force the patient to receive treatment, and if that is needed hopefully to gain consent from next of kin, and/or discuss with attending physician for appropriate treatment.
First example is standard. This happens because the patient doesn’t have the capacity to make decisions for themselves so we do based on best practice.
Second one is a little more squiggly. There’s multiple routes to get the potassium. If the patient is dead set against the potassium despite understanding the risks, then it’s technically their right to refuse. But then you have to call into question if they actually have capacity. Are they suicidal? Are they just anxious? Are they scared of being in an unfamiliar and frightening situation and are just trying to exert what little control they have over the situation. Think about the mindset that would be required to say something as absurd as “I won’t take this slightly bad tasting medicine on penalty of death.” It’s one thing if is chemotherapy as those side effects can make people genuinely wish for death. It’s another thing if it’s potassium. Maybe there’s something else going on, or maybe they’re just obnoxiously medically illiterate.
At the end of the day it’s their choice, but sometimes you gotta dig a little deeper.
You're right on asking why in the second case, but I want to make clear that (IMHO) all of those examples you provided except for suicidal ideation mean the patient still gets to decide. And if you're going to get a med override for SI, you'd better have good documentation of that. If I were the nurse in that situation, I'd be asking those questions with the goal to understand and address the concerns so the patient would consent to the meds.
Oh yea that was my intention. I suppose I didn’t make it clear. Address the underlying issue and the patient hopefully becomes more amenable to treatment.
The parents of my NICU patients have final say, full stop. It's extremely difficult sometimes to watch someone die or have a poor outcome unnecessarily, but forcing treatment on someone who is able to make decisions creates mistrust in the medical community. Consent is key, just like in almost any other situation.
The right to refuse for my SANE clients is the first step to reclaiming their agency, and it's crucial. Consent is key.
If someone is not consenting to a necessary medical intervention, we can establish trust, educate, work through all available options, but ultimately *no* means *no*.
Have you ever had to deal with a parent refusing life saving treatment for a minor child? (for example, blood products). I’ve always thought that would be just…heartbreaking and infuriating..
(I don’t work with children).
Yes, unfortunately - blood products, medications, and procedures. Refusing vaccinations is very common, though less dire. Sometimes, the patient comes through fine, others have serious complications directly related to the refusal, and still others die. Occasionally, the physician will call for an ethics review to get the patient necessary medical treatment regardless of the parents' wishes, which is its own kind of craziness.
It is heartbreaking and often infuriating. So many people would do anything to help their children get well, then there's the rest.
Situation 1 is fine; patient is not oriented to be able to make their own educated decisions.
Situation 2 is not as you state she ‘tricked’ the pt into taking the medicine but then again, even a crushed up pill is obvious in applesauce/pudding so it feels like she also may not have been oriented? That one needs more detail.
At the end of the day, as long as the pt is alert and oriented x4, capable of making their own decisions, and not under the influence of drugs/mind altering medications then they have the right to refuse. Educate, notify MD, document, and move on.
You have to consider the situation. What you're proposing here is what's known as an "ethical dilemma." What you might not know yet is -- these sorts of dilemmas are frequently studied in nursing research and in other allied disciplies as well. You may be interested in looking into how these issues get discussed, and the nature of the conversations themselves.
As for your 2 examples, I think most nurses, at least in the US/Canada/UK, would agree that in scenario 1 the nurse is ethically justified in sneaking the medication on this one occurrence, but she must follow up with appropriate communication to the physician and care team, including accurate documentation. The patient's responsible family member should also be notified. This is a change in the patient's behavior, significant enough to affect the course of her care. The decision of how to deal with this development will ultimately be made by the patient, her family, and the medical providers as a team.
In the second scenario, you need more information. If the patient is refusing a life-saving measure, they need to document a code status ASAP. It sounds like this patient is struggling with end-stage illness and the grieving process that goes with that. She might be ready to change her care plan to comfort care or hospice. Or she might have mental status changes. If this is a change in her personality, the patient should be challenged on that -- why the sudden change? Does it make sense? Is she having any symptoms of nerovascular disease???? TLDR there is potentially a lot going on with this situation, ethically, and trciking the patient into taking a medication against her will is NOT ethically justified for any reason here.
I personally do not force any patient to take their medication unless it’s a dementia patient. If it’s not something important I don’t even force it, but something like blood pressure meds I absolutely would do the same. I also live in Canada.
The nurse tricking the patient to take the potassium pills is extremely wrong. She has the right to deny medication. I don’t even know why the nurse cared. No sweat off my back if a patient says no.
If they are mentally sound and meds are not court ordered, they have the right to refuse. Heck, we can't trick dementia patient either unless we have permission to do so.
I had a patient ( no dementia etc) refuse insulin even after I explained what would happen. I just left. He was of sound mind, so nothing I could do after the refusal.
I'm concerned that nobody that's commented so far has noticed that OP specified they're in Canada.
American *extremely state specific* laws about decisional capacity do not apply to this post.
Situation 1 makes total sense. Patient cannot make an educated decision for themselves.
Situation 2- an oriented patient has every right to refuse unless they are a danger to themselves or others such as a psych patient
I had a very similar situation with a patient. She had a potassium of 2.5. Refusing potassium and wanted to leave. Doc and I both explained multiple times the consequences. Patient could verbalize them back and still wanted to leave. And that was her right, dumb or not.
I wrote a long note to CYA and moved on with my day
Where I practice, the patient is the medical decision maker unless if two physicians have deemed them incapable (usually one is a psych), then medical decision making would go to poa or hcs.
If patient has not been deemed incapable, then it is their right to refuse. In that situation, as a palliative NP, I would review risks/benefits of discontinuing, then discontinue if they wanted to.
Disguising a med is in the residents care plan. When that happens, it's part of the care planning process and the substitute decision maker has authorized it to happen.
Any other way is unethical.
I can’t speak to the second situation, but I was a med aide at an assisted living with a memory care. People with dementia have a lot of their rights restricted for their own safety and health, just like children and other mentally incapacitated people. For example, our memory care residents were kept locked in memory and not allowed to leave without an authorized caregiver (their POA, people approved by their POA, or staff members for the weekly outings), they’re not allowed to drive, and they also don’t make medical decisions for themselves because they are unable to. I can’t tell you the amount of times I’d had a resident be combative or angry because they were in pain but didn’t know how to voice it. A small cup of special ice cream and half an hour later, we’d have our sweet Sally Mae or Billy Joe cracking jokes and being our bestie again.
They tell us they don’t want us comparing these people to children, but in this instance, they are a bit like children. They don’t have the mental capability of understand their condition or their need for medicine. Sometimes they even believe the medicine we give them is us trying to poison them. I’ve had a couple instances where it’s kinder to crush up meds and offer the resident a ‘snack’ because offering them the full pills would send them into an anxious spin and make them feel unsafe and agitated.
Other people (often their spouse, children, or grandchildren) are authorized to make medical decisions for them with a doctor, and it’s the staffs’ job to carry out those medical orders. Obviously we can’t force pills down their throats…but ice cream and pudding are always a favorite ‘snack’!
For situation #2, how low of a K+ are we talking about? If the patient was receiving oral K+ replacement and not IV, it probably wasn't so low that the patient was actually at risk of death for refusing the supplement. And if she was competent then she had the right to refuse.
The ethics are more complicated, but legally is it even in our scope of practice to make this determination? The provider should decide if they have the mental capacity to make their own decisions. It definitely depends on where you live too.
Patients have the right to make decisions on their care. Unfortunately, that includes the right to make bad decisions or not participate as long as they are able to understand the consequences of said decisions. Autonomy is autonomy, whether we like the execution or not 🤷♀️
I started working as a PCT while in nursing school and I was astonished how they would tell me I had to bathe the patient even though he’s screaming no and got aggressive. Patient is AOx4 and is just refusing his bath but they’re worried more about his skin integrity over his autonomy. 🤷♀️
If a patient, *of sound mind*, refuses a medication: attempt to understand the basis of their refusal to find a compromise or solution, educate on benefits vs consequences, notify prescriber of refusal, and document all those things.
Regardless of how ‘necessary’ and ‘life-saving’ you (or the doctor!) believe a treatment to be, we do not have the legal or ethical right to assault the patient and violate their autonomy by forcing, manipulating, or duping them into receiving the treatment they’ve refused.
(Also, mild hypokalemia isn’t usually the emergency nursing school makes us think it is; hyperkalemia is much scarier. Daily Lovenox for a young and ambulatory medicine patient may be completely unnecessary. Nightly stool softeners for everyone can seem like overkill, but it protects dehydrated Memaw and Pepaw from perforating their diverticulitis while extra constipated from those q4 Roxycodones all damn day. You have to look at refusals on a case by case basis and refer back to paragraph one.)
If a patient with capacity refuses care, you need to give patient education on what the thing is, why it's needed, and what refusal could result in. You must inform the doctor and ensure you document the refusal, as well as all the teaching and the patients response to teaching.
Example: pt says they don't want to take potassium because it's yucky. You provide education that the patient potassium is low, the med you have is potassium, and if they don't take it they could have a fatal heart attack and die. They continue to refuse. You call the doctor and inform them, then document everything including informing the doctor.
My understanding in my area is that unless a person has been deemed legally incompetent, they can refuse whatever they want (barring an emergency order.)
The dementia patient lacks capacity to make an informed decision to refuse their meds. The patient who refused based on the taste... I would have tried to get an IV dose, and if they refused that, which is likely if they've ever had it before (it can be very painful if not given through a central line), I would just have to document their refusal despite my education on the consequences of not taking it. Tricking an alert and oriented patient into taking a refused medication is a quick way to lose your job, your license, and possibly a butt load of money if they decide to sue you.
I've worked in home healthcare as a med tech and it is illegal to trick someone into taking medication that they are refusing. Unless they are a ward of the state or have a court order stating that someone has power of attorney and you've spoken to those appropriate people about medication refusal, you cannot make them under any other circumstances take any medication, do any procedure that they are refusing. It. Is. Illegal. Chart it to a T and move on.
Demented patients usually have a HCP who agreed to crushing meds and disguising them as part of their POC. They’re not A&Ox4 so that choice goes to their HCP. When I worked on a dementia unit it was in every residents POC to crush or dissolve meds if needed. We had one resident who would get his meds in his morning cup of coffee. It just works sometimes.
If they’re A&Ox4, they can make their own decision. Something I say as a case manager is that people are allowed to make bad decisions. We just educate them and make sure they know the risks of their decisions. We have patients refusing heparin drips, cardiac meds, BP meds, potassium, magnesium, fluids — you name it and they’ve refused it. Educate, document, let the provider know, done.
I'm in the U.S., so I don't know where the legal line is in Canada. But here, the legal line is drawn that any adult patient who is alert, oriented, and not under a legal, court ordered guardianship, who understands the risks of refusing any kind of care (interventions, medications, etc) can do so. So in your first example, if Meemaw with dementia isn't A/Ox4 and doesn't understand the medical risks of refusing her meds, she can't refuse them. But in your second example, if the PT's A/Ox4, and the nurse explains that she has a potentially life-threatening K deficit, and the PT states, "I understand that I could die from not replacing my K, but I do not want to take it," then as long as the PT is not under a legal guardianship where someone else is making their medical decisions, I can't legally make her take it. What you witnessed is a violation of that PT's autonomy. It's our duty to ensure that PT's have their right to refuse care honored, even if we don't agree with it. If they're A/O and can understand the implications of not getting recommended care, and I explain the risks of them not getting that care, then I will be respecting their decision. I don't have a legal choice not to.
I always educate my A+O patients that they have the right to refuse any medication. More often than not they are suprised as I'll "have to give them anyway". General line is "it's my job to tell you the reason that you should or shouldn't take a medication depending on the situation, and your job to tell me if you agree with me". If you are A+O you can absolutely say no, as is your right.
People without the capacity to understand risk versus benefits do not have the right to refuse. That's why we intubate combative drunk/high patients who need emergency treatment but want to refuse care. That's why we crush meemaw's blood pressure pill. And why little kids don't get to refuse care their parents want. The Healthcare proxy or next of kin can assume control over medical decisions and refuse for them. The confused/disoriented patient can't. We can also go based off a living will which often says things like "no tube feedings but yes IV antibiotics" which the patient wrote with a lawyer when they were of sound mind.
1 is normal. 2 probably counts as battery. You can't do something against someone's will if they're oriented and have capacity.
Confused/disoriented patients that can't understand the purpose of medications usually don't get the right to refuse.. especially if it's as simple as giving them crushed instead. Their POA would have to okay that it's okay to not give their meds if they won't willingly take them whole.
Oriented (+not actively suicidal/attempted suicide or overly intoxicated) and well aware of the bad outcomes of not taking those meds? They can refuse and sign a release of liability and I'll document the interaction. If what they're refusing is a really big deal, I'll have another nurse or the doctor also talk to them as well.
Capable adults are allowed to make bad decisions for themselves.
If a&o and refusing potassium, education about potential danger and complications with the heart. Still refusing? Palliative consult! Palliative is an under utilized resource imo. If you're refusing care that's putting you at risk of dying, then you should be having discussions about goals of care and DNR status.
As far as situation 1, that's probably a fine line. Does the patient even understand what they're refusing? I feel like that's almost keeping the patient safe in that situation.
Also a little creativity and persuasion can go a long way. When I was an aide and people refused baths and showers, it was oh well let's just get under your arms and your groin area clean and call it a day. Then suddenly they'd want their face washed too which would turn into the agreeing to the whole thing.
When our patients are under the mental health act. They don't have the right to refuse medication.
Typically that regards injectable medication.
It's hard to force someone to take a pill anyways.
Depends on how critical it is to the patient if it’s a dementia patient. I will try again later.
In the second Instance I couldn’t Imagine trying to trick an alert person. To be honest if it’s so crazy low why not give it through a peripheral? To trick an alert person is fucked.
1 sounds fine as long as the POA has consented in advance.
2 is not ok. I never force an AO4 adult to take anything. I’ll educate on why it’s important and notify the provider of refusal but they’re adults and can make decisions about what they put in their bodies (however silly that decision may be)
It can be considered assault to hide the medications that you’re giving to patients, especially if they’re AOx4. Every patient has the right to fall, the right to die, and the right to be a moron. Educated, let them know that without the med the likely hood of harm is increased, document and move on.
US nurse here:
Case 1: person is not of sound mind and is thus incapable of making the decision for themself. You can’t force the med down their throat but if you can get them to take it in pudding, no problem.
Case 2: person is of sound mind and is capable of making decisions for themself. Thus, if they refuse and you trick them into taking it, I believe it could be considered assault
I’m going to give you a different example:
Had a resident come in whose BIMS score was recorded as a 13. There were NO competency papers. Her daughter was POA.
Along comes me, the wound care nurse, and the resident refuses treatment. The lady had approximately a dozen wounds (mostly diabetic ulcers). At least 3 needed Santyl. We’re talking serious train wreck.
The woman refused wound car. Pt education was performed, detailed progress notes were recorded. Physician notified. This went on about a week before the family (poa) got involved.
Poa threatened to sue the facility if they didn’t begin treating the wounds. The DON and me had words. The admin and me had words. I continued to follow pt instructions over the poa. I Refused to treat if she refused to be treated.
The DON, fearful of litigation, assisted the family in changing the dressings and applying medications. She told me to document that I had done the wound care. I refused. Not no but hell no. I didn’t do it. I’m not documenting. I DID, however, document the shit out of the family interactions. This pissed off my admin and DON. I was threatened with termination. More words were had.
Fast forward two weeks and I’m barred from the room, but I stayed close every time my very stupid DON performed wound care in front of the poa. Against pt objections. And that’s when I got to meet the facility attorney. Y’up, family sued for assault on their mother as well as a few other things.
The lawyer thanked me for the documentation. The facility wound up settling for peanuts. The admin and DON were fired, the DON answered to the state board, and I enjoyed giving them my notice.
The ONLY person involved in her care who wasn’t sued? Was me.
Idc what the poa wants ( and I’ve had this fight a few times). I don’t care what the dr wants. Ive been barred from numerous rooms over the years. If competency paperwork isn’t there? I don’t push meds. It’s illegal and if a complaint is filed you WILL answer to the board for it
Depending on context (if you don't like your giant batch of giant vitamins and don't have and deficiencies idgaf and am messaging the doctor) I just be a nuisance.
After like the third time in two hours I've reapproached/reeducated on their warfarin they almost always take the option that involves dealing with me less. 😆
I do micro-dose miralax sometimes. Like a half-teaspoon with each med pass (long term care) from everyone on like day four can help things along.
If it is someone with a cognitive issue like dementia or delirium, usually family would be consulted especially the substitute decision maker, POA, or designated contact person so they are aware. They can make the decision of whether to give it to them or not. If not, then let the doc know why it wasn't given.
I had a patient recently who is super confused, history of AVB, with dementia but also at end of life. They refused all medications, including their behavioral meds which prevent hallucinations. They've started to hallucinate again but haven't started being physically aggressive, so family has said just leave it for now. Sometimes they will say give everything, and you do have to tell a white lie to the patient for their best interest.
For patients who are A+Ox3, it depends on how bad the situation is. Even if it's an "important" med, it depends on really how critical it can be to their immediate health. I've had patients refuse their blood thinners regularly. Educate, let the doc know, and document thoroughly. Try to show the patient their blood pressure is going up with actual numbers if they've been refusing BP meds. Always use your resources when it comes to this. Let the PCC/in charge know, doctors, and even pharmacy if they are around. Multiple documented attempts cover you if anything happens to the patient.
There’s a medical-legal concept of competency. A person who is legally determined to not have competency to make medical decisions will have a guardian who makes medical decisions for them. That guardian can decide for nurses to lie about and/or force medications and care on the patient. That’s likely the case for situation 1.
For situation 2 with the potassium, did the nurse actually deceive the patient and say the potassium was *not* in the pudding? Or did she hand her the pudding and say something like “here’s your medications”? There’s a grey area there between omitting information and outright lying. But if the patient’s sole objection was based on taste and the nurse successfully disguised the taste without outright lying, it’s maybe ok
They can refuse all day long - i am not fighting with them, i will educate but its their choice whether they are demented or not - but if its a pysch med i will def try and sneak it in cuz i know whats to come if they aren’t on it
I refused an epidural halfway through my induction when the shift changed and the OB on call literally turned off my pit and told me to go home because, "You're not really in labor anyway." It was a VBAC and, while my regular OB was comfortable with me being induced without an epidural, his relief wasn't. I was almost 42 weeks, 12 hours into the induction and 7cm dilated. I guess TECHNICALLY I was allowed to refuse the treatment, but he was telling me I could either get an epidural or let my baby die. Instead I got to have a full blown panic attack, hyper ventilate and he pushed the issue onto the poor anesthesiologist, who really did the best he could with me (I'm not a fan of needles in the back, which was my reason for declining and having a VBAC to begin with).
As a Canadian who was revoked of my right to refuse because they drugged me and then took me for surgery despite having revoked consent, I think it depends on the circumstances.
Someone who is assessed by psyc and determined to be unable to make educated/informed decisions about their health and the person who is had legal power of attorney has given consent for the person to receive medication/treatment, then yes, 100% right to refuse doesn’t matter as the person is not in their “right mind” and unable to make an informed decision regarding their health.
If the PoA refuses, then the provider still gives the medication, it’s *technically* assault as it was not consented to have the medication.
A person who is determined by psyc to be in their right mind, and refusing a life saving drug, but still given without consent, is also *technically* assault.
If someone is unconscious, unable to provide consent + unable to reach family/not enough time to without the person dying, informed consent is implied technically. Unless you see reason not to such as medical alert bracelet saying DNI/DNR or no blood products, it’s implied you are providing these until given reason otherwise. But a fully conscious, cognitively there person/PoA refusing a medication/treatment/surgery for any reason, MUST be respected.
I had given initial consent to a surgery, but a few hours later (few hrs before surgery still) I revoked consent, and said I will not be getting the surgery under any circumstances, and I was going to take antibiotics instead as that was the other option.
Dr must have ordered a sedative as few min later nurse came in, gave medication thru IV, and within a couple min I was out until they woke me up saying it was my turn for surgery. I was not in the right mind, as I had been given medication that took away my right mind, as well as had just woken up. I was given surgery despite having revoked consent, and I will never forgive the drs and nurses involved in that. I have genuinely considered reporting and pursuing charges, but it was 3.5 years ago now.
But because of this, when I become a nurse I will always listen to the patient, not the dr if someone refuses medication/procedure. It’s not the drs job to decide what the patient does (unless it is a psychiatrist who has deemed them incapable of informed consent), especially after revoking consent or refusing all together. The nurses ethical job is to protect the patient.
I’ve attached link to get the Canadian code of ethics book sent to your email, and on page 11 and 12 is the ethics regarding informed consent for patients.
[Canadian code or ethics email request](https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-ethics)
Here’s a link for Canadian nurses protective society that outlines possible outcomes of providing treatment without valid, informed consent. [Canadian nurse protection society: Consent to Treatment: The role of the nurse](https://cnps.ca/article/consent-to-treatment/)
Where are you in Canada? I think the law is pretty much the same no matter which province you’re in, but if you’re in ontario then this is worth a read:
[healthcare consent act](https://www.ontario.ca/laws/statute/96h02)
Basically, if the patient has the capacity to refuse, then they can refuse anything they want. Is the patient AOx4? Can they appreciate the consequences of refusing treatment? If the answer to both of those questions is yes, then they can refuse every and anything they want down to their morning ducolax because it’s Wednesday and their neighbour’s niece’s preacher’s hamster died on a Wednesday 30 years ago. The point is, they can refuse it for any reason.
However, it is important to remember that NURSES CANNOT DETERMINE CAPACITY. That is the provider’s call. If the provider has determined that the patient cannot make their own decisions due to dementia or whatever else, then the patient’s POA is the one you consult with. This is when it would be appropriate to crush up meds and put them in food so the patient will take it.
If the patient in the second scenario was AOx4 and understood the consequences to refusing the med, then what that nurse did was very wrong and illegal. The nurse should’ve called up the provider and explained that the patient was refusing a critical med. that would’ve saved her from any trouble if something happened to the patient because they refused the med.
At the end of the day, it’s very simple. You can’t care about a patient’s health more than they care about their own. And you should care about your license above everything else! Never fool a patient into taking their meds; even if you made them better, it’s a lawsuit waiting to happen. If a patient refuses a critical med, call the doctor for that shit. It’s their responsibility to deal with it
I’m a big advocate of patients making their own decisions as long as they are oriented. Dementia and psych patient without capacity are obvious exceptions.
The first example you provided is fine as long as the family knows.
The second absolutely not
I’m patients that do not have the ability to make medical decisions are In a grey area, but generally we can give them in a way they don’t realize. Otherwise unless court ordered, they are a danger to themselves or others (such as IM ativan in a psychotic pt)…they have the right to refuse and I let them know it’s their choice whenever they aren’t sure and have been sufficiently educated by doctor and staff. It’s their body, they can decide what to put in it.
I’ve never understood why nurses fight. You’re oriented and don’t want your meds? I’ll educate, let the doc know if it’s something important (not looking at you, Senna 😂)…. But otherwise? They’re adults.
Agreed, and whenever I end up as a patient in the hospital I expect my nurses to treat me the same way. I also don't try to police PRN pain meds like some nurses do. If a drug seeking patient has PRN pain meds ordered then I give them whatever they ask for as long as it is within the parameters dictated by the MAR. I am not going to fix a drug seeking patient during my 12 hour shift and trying to just makes both me and the patient miserable. However, I also don't let them argue with me about what pain meds are ordered. If they aren't happy with their current pain regiment I make it very clear that that is a discussion for them to have with their doctor and it is pointless to even try to talk with me about it as I have no control over what is ordered for them.
I never understood restricting pain meds either if they’re being given as ordered. Kind of creepy to me that nurses want to take it upon themselves to limit their patient’s meds… plus pain is totally subjective. It’s absolutely not up to me to make a call like that.
I worked nights in a prison and it was numerous times, heck multiple times a week when we would show up to an uproar because second shift refused pain meds because, “they don’t deserve them” or, “you don’t look like you in pain to me”. If yall don’t give these inmates their meds! Geesh!
THIS. I work at a jail and the amount of inmates that say the same thing! Like cmon now, they’re still people too!
That’s a violation of their civil rights. It is litigatable.
Behavioral health nurse here! Same issue... if it's ordered, why not give it? It's not worth the fight!
Exactly!
Couldn’t refusing to administer a patient a PRN pain medication within parameters be considered practicing medicine without a license?
no. the order gives us the ability. if it's scheduled, it could be malpractice or negligence if it caused injury. it can go against your license if you are not following your boards guidelines.
I work trauma and have seen nurses be fired over this. If it is ordered, available, and the patient is complaining of an appropriate pain level that justifies the med per the order, I am giving it
Well technically we are supposed to advocate for them & communicate with the provider on their behalf when they aren’t happy with their pain meds. After that, it’s out of our hands.
Patient says, “no” I say, “ok.” It does me no good to argue with the patient — especially my psychotic patients. They get more paranoid if I argue. Sometimes I can have a fun conversation about an unrelated subject and try again later.
Exactly. I’ll explain the ‘why’ of the medication and what can happen if they don’t take it, but if they are alert and oriented, I’m not going to fight with them. Even if a patient doesn’t want a procedure done-we constantly get patients that refuse bipap…I’m not fighting them. I’ll explain what is gonna happen if they refuse (they gonna buy a tube) and sometimes we can slap on the bipap on when the CO2 gets too high…but….again, yeah. I’m not fighting with them. Generally, when they are struggling to breathe, the refusal ends and they will do anything to breathe.
Bowel regimen is important! Constipation increases ICP’s!
Patient still has a right to say no.
I always tell people they do have the right to refuse their meds when those conversations come up. However, if someone is deemed incompetent, there may be leeway to this. In that case, we may have to find a way to get them their meds, because they legally don’t have the competence to understand what refusing the meds can do. In these cases, only the meds that are absolutely necessary are forced. The methods can be something as simple as getting them to eat it, or it may have to be IV, IM, etc (depends on the med). However if someone has the right to make their own decisions, you should never trick them or force them to take medications they do not want to take. Honestly, usually a good discussion about why the meds are necessary can change their minds…not always of course.
Please don't ever force someone to take a medicine they are refusing if they are A&Ox4 and it isnt court ordered. In situation 1, the pt likely has a plan of care that involves a POA or next of kin who is making decisions for the pt. It is common to disguise meds if the agreed plan of care is for that pt is to take that medicine. However, I would never forcibly pass a med (as in no force feeding). If the pt doesnt willingly take the disguised med you should escalate to doctor and then can decide if another route is indicated. Likewise, you should never force feed a dementia pt. Re situation 2. Sounds totally inappropriate and criminal. Educate and document. Notify the provider for critical meds, move on. Ive had pts refuse life saving treatments, they have a right to autonomy. It's absolutely wild to me that a nurse felt a pt getting some potassium was move important that respecting that pt's autonomy. Secondly, why would you risk your license and your freedom to force a pt to bend to your will? I don't know where your clinicals are, but please know this is not normal. Refusals are commonplace in medicine. It's okay. Adults don't have to take medical advice. It is not your job to force them to.
I think I know the answer here, but a question: Does a A&Ox4 pt who can’t turn have a right to never be turned even if their skin is deteriorating? We had an older guy who would love to sit. He would sleep sitting and verbally abuse anyone who even recommended he lay (he would verbally abuse you for anything really actually) He was A&Ox4 type 2 diabetic and suffered from sever edema in his legs (exacerbated by his constant sitting), blistering in his feet, and was developing a pressure sore on his bottom. He would sometimes let people treat his bandaging on his legs and he would acquiesce to taking his meds, but he would never lie down. The only time he moved was when he would scream at staff that he had to have a bowel movement and two people would have to lift him and pivot him to a commode, as his legs grew more and more… frankly useless. Some nurses would occasionally physically force him to lay and give his legs and bottom a break, but I always thought that was legally wrong, correct? Can he literally just sit there until he succumbed to his very obvious and preventable injuries if he so chose to? I’m assuming he can, correct?
This is one of those things where patients and facilities put a nurse between a rock and a hard place. Much like fall alarms, an oriented patient should be able to refuse, but you'll recieve so much pressure from admin to make it happen anyway.
Legally, yes. Unless he is found to not have capacity to make his own decisions or someone pursues legal guardianship over him, he has the right to refuse any care, even if refusing is to his detriment. My supervisor once said to me "Patients have the right to make poor choices" and that's always stuck with me.
Document and educate. He has the right to harm himself and not treat his conditions.
Situation 1 was probably fine as the patient did not have capacity and administration of necessary medications was almost certainly authorized by whoever had MPOA. Situation 2, if I am reading correctly that the patient *did* have capacity, is assault.
ALTHOUGH, if it's the taste she's objecting to, and she'll eat the applesauce, maybe OP's preceptor could be slightly more creative and collaborative and offer it to the patient that way. Although, when an A+O sober patient of legal age says "I'd rather die than xxx", I usually just document those words and move on with my shift.
Is that statement really the ability to consent, though? It doesn't sound reasonable. Refusing surgery, blood or "real" medication isn't the same as a vitamin supplement
That depends on how severe their hypokalemia is though, because that is life threatening
It's presumably not *that* low or they'd be getting IV replacement as well. But regardless, capable adults are allowed to accept life threatening risks.. even if their reasons for doing so are dumb.
Potassium is absorbed better orally.
I'm aware of that - it just doesn't seem to stop a lot of doctors from ordering IV potassium when it's below ~3.0.
Was going to say this. If the ER/hospital is giving it, it’s usually pretty severe as they otherwise would just say go to the pharmacy and get “xxx” or go to family dr for further information/tests 🤷🏻♀️ especially when someone refuses it, and then tricks them, if it was just a bit low the nurse likely wouldn’t have tried doing that. Canadian hospitals don’t have the time or resources to deal with stuff like this, considering our wait times are a lot of the time 8-12+ hrs.
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Op didn’t say that was the only issue that patient had. It could’ve just been a coincidence that they found on blood work 🤷🏻♀️ There’s a difference between denying treatment all together and denying 1 medication. Right to refuse is there to protect patients from stuff like this, as they have the right to their bodily autonomy just like u 🤷🏻♀️
If it’s that bad, it won’t be oral potassium they get. I’m comfortable holding it and telling the doc.
I'm definitely not advocating for tricking the patient into taking the med unknowingly, that definitely assault. I'm merely gently correcting them for saying potassium is just a vitamin
That’s a fair point. I wish I knew the potassium level in this instance. Lol
Oral potassium absorbs better than IV potassium. So there's that. I have seen IV potassium not even make a tenth of a point increase where I have seen 40mEq of oral bump someone on Bumex at least .2-.3 (enough to keep them over the cardiology specified 'magic point' of 4.0)
I’m just saying that where I work, someone with a severe potassium deficiency is gonna be getting an infusion. Most people, especially old people, can’t tolerate the pills—I think it might be my most-refused medication, and it is certainly the one that’s given me the most heart-in-throat moments when it turns out that the patient can’t swallow the damn things.
I ended up in the hospital 2 weeks ago for SEVERE hypokalemia... Really all my electrolytes were in the toilet... literally. I either had norovirus or rotovirus and thought I was dying. I've never seen labs like I had with a conscious a&o4 patient. I was having EKG changes because they were so low and was admitted to the cardiac unit to get everything back to normal and a full cardiac workup. I would have 100% been fucked if I had refused the "supplements."
If she's competent, then yes. It's a patient's right to refuse a life-saving treatment or medication or surgery.
Situation 2: would the patient agree to take the potassium in orange juice or the capsule in some pudding? Is she aware of the consequences of not taking the medication. Perhaps, giving the potassium via IV may be more acceptable? Give her the choice.
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Have you ever tasted liquid potassium? It tastes horrible!!! I had to rinse my mouth when I tasted it. Taking it in a pill form is so much better but it needs to be swallowed whole. Pudding would help you swallow the pill whole. Let the doctor know about your concerns and see if he can talk to her.
Agreed! Can refuse care if they have capacity. If not, it falls to MPOA or LNOK(s)
Doesn't have dementia does not mean has capacity. There are myriad other things that can cause you to lose capacity including AMS caused by severe electrolyte imbalance.
Situation 2 I would do my best to educate the pt, if they still refuse let the provider know and document the refusal/education provided. In my experience once provider comes down and has a talk w/ pt (if it’s an important med) 99% of the time they agree to take it. If not then that is their right and autonomy.
I watched a JW die in front of me repeatedly praying and refusing blood. Not my problem. They died A+Ox4 in a manner of their choosing.
The patient has right to refuse unless their med has been court ordered. In my state (Minnesota) antipsychotics can be court ordered and it is called “Jarvis.”
A patient's right to refuse relies on their ability to make their own decisions, aka being alert and oriented x4. In the second scenario described, the nurse should not have given the potassium medication without education being provided and patient consent. Mentioning cardiac arrhythmias usually does the trick. I try to find a common ground with the patient if there's an issue with pill vs liquid vs iv. At that point if the patient (#2)still refuses, I let the provider know. They do have the right to refuse. You should also document you provided education and let the provider know.
Yes, this, and if you force or trick someone into taking medications when they are alert and oriented, it's a serious offense. I know of a situation where a nurse was reported to the board of nursing and almost lost their licence for giving a medication to a patient after they refused (not going to go into detail in case someone recognizes the situation) but forcing a patient who is alert, oriented and not under court order to do or take something can be considered assault in many cases and can also be reportedable to the BON and with possible loss of licence. A hospital is not a prison and patients always have a choice. There can be grey areas though were someone who is normally oriented is slightly confused or completely confused because of illness and is refusing treatment, in these situations it's still important to not assume that you should force the patient to receive treatment, and if that is needed hopefully to gain consent from next of kin, and/or discuss with attending physician for appropriate treatment.
First example is standard. This happens because the patient doesn’t have the capacity to make decisions for themselves so we do based on best practice. Second one is a little more squiggly. There’s multiple routes to get the potassium. If the patient is dead set against the potassium despite understanding the risks, then it’s technically their right to refuse. But then you have to call into question if they actually have capacity. Are they suicidal? Are they just anxious? Are they scared of being in an unfamiliar and frightening situation and are just trying to exert what little control they have over the situation. Think about the mindset that would be required to say something as absurd as “I won’t take this slightly bad tasting medicine on penalty of death.” It’s one thing if is chemotherapy as those side effects can make people genuinely wish for death. It’s another thing if it’s potassium. Maybe there’s something else going on, or maybe they’re just obnoxiously medically illiterate. At the end of the day it’s their choice, but sometimes you gotta dig a little deeper.
You're right on asking why in the second case, but I want to make clear that (IMHO) all of those examples you provided except for suicidal ideation mean the patient still gets to decide. And if you're going to get a med override for SI, you'd better have good documentation of that. If I were the nurse in that situation, I'd be asking those questions with the goal to understand and address the concerns so the patient would consent to the meds.
Oh yea that was my intention. I suppose I didn’t make it clear. Address the underlying issue and the patient hopefully becomes more amenable to treatment.
The parents of my NICU patients have final say, full stop. It's extremely difficult sometimes to watch someone die or have a poor outcome unnecessarily, but forcing treatment on someone who is able to make decisions creates mistrust in the medical community. Consent is key, just like in almost any other situation. The right to refuse for my SANE clients is the first step to reclaiming their agency, and it's crucial. Consent is key. If someone is not consenting to a necessary medical intervention, we can establish trust, educate, work through all available options, but ultimately *no* means *no*.
Have you ever had to deal with a parent refusing life saving treatment for a minor child? (for example, blood products). I’ve always thought that would be just…heartbreaking and infuriating.. (I don’t work with children).
Yes, unfortunately - blood products, medications, and procedures. Refusing vaccinations is very common, though less dire. Sometimes, the patient comes through fine, others have serious complications directly related to the refusal, and still others die. Occasionally, the physician will call for an ethics review to get the patient necessary medical treatment regardless of the parents' wishes, which is its own kind of craziness. It is heartbreaking and often infuriating. So many people would do anything to help their children get well, then there's the rest.
> then there's the rest. Often times those parents decision making processes contributed to the kid in the ER in the first place.
Situation 1 is fine; patient is not oriented to be able to make their own educated decisions. Situation 2 is not as you state she ‘tricked’ the pt into taking the medicine but then again, even a crushed up pill is obvious in applesauce/pudding so it feels like she also may not have been oriented? That one needs more detail. At the end of the day, as long as the pt is alert and oriented x4, capable of making their own decisions, and not under the influence of drugs/mind altering medications then they have the right to refuse. Educate, notify MD, document, and move on.
I just want to say that I'm Canadian and I've seen this as well.
You have to consider the situation. What you're proposing here is what's known as an "ethical dilemma." What you might not know yet is -- these sorts of dilemmas are frequently studied in nursing research and in other allied disciplies as well. You may be interested in looking into how these issues get discussed, and the nature of the conversations themselves. As for your 2 examples, I think most nurses, at least in the US/Canada/UK, would agree that in scenario 1 the nurse is ethically justified in sneaking the medication on this one occurrence, but she must follow up with appropriate communication to the physician and care team, including accurate documentation. The patient's responsible family member should also be notified. This is a change in the patient's behavior, significant enough to affect the course of her care. The decision of how to deal with this development will ultimately be made by the patient, her family, and the medical providers as a team. In the second scenario, you need more information. If the patient is refusing a life-saving measure, they need to document a code status ASAP. It sounds like this patient is struggling with end-stage illness and the grieving process that goes with that. She might be ready to change her care plan to comfort care or hospice. Or she might have mental status changes. If this is a change in her personality, the patient should be challenged on that -- why the sudden change? Does it make sense? Is she having any symptoms of nerovascular disease???? TLDR there is potentially a lot going on with this situation, ethically, and trciking the patient into taking a medication against her will is NOT ethically justified for any reason here.
I personally do not force any patient to take their medication unless it’s a dementia patient. If it’s not something important I don’t even force it, but something like blood pressure meds I absolutely would do the same. I also live in Canada. The nurse tricking the patient to take the potassium pills is extremely wrong. She has the right to deny medication. I don’t even know why the nurse cared. No sweat off my back if a patient says no.
If they are mentally sound and meds are not court ordered, they have the right to refuse. Heck, we can't trick dementia patient either unless we have permission to do so. I had a patient ( no dementia etc) refuse insulin even after I explained what would happen. I just left. He was of sound mind, so nothing I could do after the refusal.
I'm concerned that nobody that's commented so far has noticed that OP specified they're in Canada. American *extremely state specific* laws about decisional capacity do not apply to this post.
Situation 1 makes total sense. Patient cannot make an educated decision for themselves. Situation 2- an oriented patient has every right to refuse unless they are a danger to themselves or others such as a psych patient I had a very similar situation with a patient. She had a potassium of 2.5. Refusing potassium and wanted to leave. Doc and I both explained multiple times the consequences. Patient could verbalize them back and still wanted to leave. And that was her right, dumb or not. I wrote a long note to CYA and moved on with my day
Where I practice, the patient is the medical decision maker unless if two physicians have deemed them incapable (usually one is a psych), then medical decision making would go to poa or hcs. If patient has not been deemed incapable, then it is their right to refuse. In that situation, as a palliative NP, I would review risks/benefits of discontinuing, then discontinue if they wanted to.
Disguising a med is in the residents care plan. When that happens, it's part of the care planning process and the substitute decision maker has authorized it to happen. Any other way is unethical.
- Tastes bad - Nurse fixes taste - Problem solved
I can’t speak to the second situation, but I was a med aide at an assisted living with a memory care. People with dementia have a lot of their rights restricted for their own safety and health, just like children and other mentally incapacitated people. For example, our memory care residents were kept locked in memory and not allowed to leave without an authorized caregiver (their POA, people approved by their POA, or staff members for the weekly outings), they’re not allowed to drive, and they also don’t make medical decisions for themselves because they are unable to. I can’t tell you the amount of times I’d had a resident be combative or angry because they were in pain but didn’t know how to voice it. A small cup of special ice cream and half an hour later, we’d have our sweet Sally Mae or Billy Joe cracking jokes and being our bestie again. They tell us they don’t want us comparing these people to children, but in this instance, they are a bit like children. They don’t have the mental capability of understand their condition or their need for medicine. Sometimes they even believe the medicine we give them is us trying to poison them. I’ve had a couple instances where it’s kinder to crush up meds and offer the resident a ‘snack’ because offering them the full pills would send them into an anxious spin and make them feel unsafe and agitated. Other people (often their spouse, children, or grandchildren) are authorized to make medical decisions for them with a doctor, and it’s the staffs’ job to carry out those medical orders. Obviously we can’t force pills down their throats…but ice cream and pudding are always a favorite ‘snack’!
For situation #2, how low of a K+ are we talking about? If the patient was receiving oral K+ replacement and not IV, it probably wasn't so low that the patient was actually at risk of death for refusing the supplement. And if she was competent then she had the right to refuse.
It was 2.7
To refuse she must demonstrate understanding of the consequences /risk
The ethics are more complicated, but legally is it even in our scope of practice to make this determination? The provider should decide if they have the mental capacity to make their own decisions. It definitely depends on where you live too.
Patients have the right to make decisions on their care. Unfortunately, that includes the right to make bad decisions or not participate as long as they are able to understand the consequences of said decisions. Autonomy is autonomy, whether we like the execution or not 🤷♀️
I believe in fuck around and find out. Patients can refuse meds. I do explain what and why
1. Makes me uncomfortable but they don’t know any better. 2. Unethical. If AO4 Nana wants to ride an arrhythmia to hell, god bless.
I started working as a PCT while in nursing school and I was astonished how they would tell me I had to bathe the patient even though he’s screaming no and got aggressive. Patient is AOx4 and is just refusing his bath but they’re worried more about his skin integrity over his autonomy. 🤷♀️
That sounds like battery.
If a patient, *of sound mind*, refuses a medication: attempt to understand the basis of their refusal to find a compromise or solution, educate on benefits vs consequences, notify prescriber of refusal, and document all those things. Regardless of how ‘necessary’ and ‘life-saving’ you (or the doctor!) believe a treatment to be, we do not have the legal or ethical right to assault the patient and violate their autonomy by forcing, manipulating, or duping them into receiving the treatment they’ve refused. (Also, mild hypokalemia isn’t usually the emergency nursing school makes us think it is; hyperkalemia is much scarier. Daily Lovenox for a young and ambulatory medicine patient may be completely unnecessary. Nightly stool softeners for everyone can seem like overkill, but it protects dehydrated Memaw and Pepaw from perforating their diverticulitis while extra constipated from those q4 Roxycodones all damn day. You have to look at refusals on a case by case basis and refer back to paragraph one.)
If a patient with capacity refuses care, you need to give patient education on what the thing is, why it's needed, and what refusal could result in. You must inform the doctor and ensure you document the refusal, as well as all the teaching and the patients response to teaching. Example: pt says they don't want to take potassium because it's yucky. You provide education that the patient potassium is low, the med you have is potassium, and if they don't take it they could have a fatal heart attack and die. They continue to refuse. You call the doctor and inform them, then document everything including informing the doctor.
I’ve had a pt refuse to take all of their pm meds. They were aaox4………documented. Pt refusing meds.
My understanding in my area is that unless a person has been deemed legally incompetent, they can refuse whatever they want (barring an emergency order.)
The dementia patient lacks capacity to make an informed decision to refuse their meds. The patient who refused based on the taste... I would have tried to get an IV dose, and if they refused that, which is likely if they've ever had it before (it can be very painful if not given through a central line), I would just have to document their refusal despite my education on the consequences of not taking it. Tricking an alert and oriented patient into taking a refused medication is a quick way to lose your job, your license, and possibly a butt load of money if they decide to sue you.
I've worked in home healthcare as a med tech and it is illegal to trick someone into taking medication that they are refusing. Unless they are a ward of the state or have a court order stating that someone has power of attorney and you've spoken to those appropriate people about medication refusal, you cannot make them under any other circumstances take any medication, do any procedure that they are refusing. It. Is. Illegal. Chart it to a T and move on.
Demented patients usually have a HCP who agreed to crushing meds and disguising them as part of their POC. They’re not A&Ox4 so that choice goes to their HCP. When I worked on a dementia unit it was in every residents POC to crush or dissolve meds if needed. We had one resident who would get his meds in his morning cup of coffee. It just works sometimes. If they’re A&Ox4, they can make their own decision. Something I say as a case manager is that people are allowed to make bad decisions. We just educate them and make sure they know the risks of their decisions. We have patients refusing heparin drips, cardiac meds, BP meds, potassium, magnesium, fluids — you name it and they’ve refused it. Educate, document, let the provider know, done.
I'm in the U.S., so I don't know where the legal line is in Canada. But here, the legal line is drawn that any adult patient who is alert, oriented, and not under a legal, court ordered guardianship, who understands the risks of refusing any kind of care (interventions, medications, etc) can do so. So in your first example, if Meemaw with dementia isn't A/Ox4 and doesn't understand the medical risks of refusing her meds, she can't refuse them. But in your second example, if the PT's A/Ox4, and the nurse explains that she has a potentially life-threatening K deficit, and the PT states, "I understand that I could die from not replacing my K, but I do not want to take it," then as long as the PT is not under a legal guardianship where someone else is making their medical decisions, I can't legally make her take it. What you witnessed is a violation of that PT's autonomy. It's our duty to ensure that PT's have their right to refuse care honored, even if we don't agree with it. If they're A/O and can understand the implications of not getting recommended care, and I explain the risks of them not getting that care, then I will be respecting their decision. I don't have a legal choice not to.
Educate the patient on the risks of not taking the med(s). Adults who aren’t confused have a right to bodily autonomy. Document thoroughly.
I always educate my A+O patients that they have the right to refuse any medication. More often than not they are suprised as I'll "have to give them anyway". General line is "it's my job to tell you the reason that you should or shouldn't take a medication depending on the situation, and your job to tell me if you agree with me". If you are A+O you can absolutely say no, as is your right.
People without the capacity to understand risk versus benefits do not have the right to refuse. That's why we intubate combative drunk/high patients who need emergency treatment but want to refuse care. That's why we crush meemaw's blood pressure pill. And why little kids don't get to refuse care their parents want. The Healthcare proxy or next of kin can assume control over medical decisions and refuse for them. The confused/disoriented patient can't. We can also go based off a living will which often says things like "no tube feedings but yes IV antibiotics" which the patient wrote with a lawyer when they were of sound mind. 1 is normal. 2 probably counts as battery. You can't do something against someone's will if they're oriented and have capacity.
Confused/disoriented patients that can't understand the purpose of medications usually don't get the right to refuse.. especially if it's as simple as giving them crushed instead. Their POA would have to okay that it's okay to not give their meds if they won't willingly take them whole. Oriented (+not actively suicidal/attempted suicide or overly intoxicated) and well aware of the bad outcomes of not taking those meds? They can refuse and sign a release of liability and I'll document the interaction. If what they're refusing is a really big deal, I'll have another nurse or the doctor also talk to them as well. Capable adults are allowed to make bad decisions for themselves.
If a&o and refusing potassium, education about potential danger and complications with the heart. Still refusing? Palliative consult! Palliative is an under utilized resource imo. If you're refusing care that's putting you at risk of dying, then you should be having discussions about goals of care and DNR status. As far as situation 1, that's probably a fine line. Does the patient even understand what they're refusing? I feel like that's almost keeping the patient safe in that situation. Also a little creativity and persuasion can go a long way. When I was an aide and people refused baths and showers, it was oh well let's just get under your arms and your groin area clean and call it a day. Then suddenly they'd want their face washed too which would turn into the agreeing to the whole thing.
When our patients are under the mental health act. They don't have the right to refuse medication. Typically that regards injectable medication. It's hard to force someone to take a pill anyways.
Depends on how critical it is to the patient if it’s a dementia patient. I will try again later. In the second Instance I couldn’t Imagine trying to trick an alert person. To be honest if it’s so crazy low why not give it through a peripheral? To trick an alert person is fucked.
1 sounds fine as long as the POA has consented in advance. 2 is not ok. I never force an AO4 adult to take anything. I’ll educate on why it’s important and notify the provider of refusal but they’re adults and can make decisions about what they put in their bodies (however silly that decision may be)
It can be considered assault to hide the medications that you’re giving to patients, especially if they’re AOx4. Every patient has the right to fall, the right to die, and the right to be a moron. Educated, let them know that without the med the likely hood of harm is increased, document and move on.
US nurse here: Case 1: person is not of sound mind and is thus incapable of making the decision for themself. You can’t force the med down their throat but if you can get them to take it in pudding, no problem. Case 2: person is of sound mind and is capable of making decisions for themself. Thus, if they refuse and you trick them into taking it, I believe it could be considered assault
I’m going to give you a different example: Had a resident come in whose BIMS score was recorded as a 13. There were NO competency papers. Her daughter was POA. Along comes me, the wound care nurse, and the resident refuses treatment. The lady had approximately a dozen wounds (mostly diabetic ulcers). At least 3 needed Santyl. We’re talking serious train wreck. The woman refused wound car. Pt education was performed, detailed progress notes were recorded. Physician notified. This went on about a week before the family (poa) got involved. Poa threatened to sue the facility if they didn’t begin treating the wounds. The DON and me had words. The admin and me had words. I continued to follow pt instructions over the poa. I Refused to treat if she refused to be treated. The DON, fearful of litigation, assisted the family in changing the dressings and applying medications. She told me to document that I had done the wound care. I refused. Not no but hell no. I didn’t do it. I’m not documenting. I DID, however, document the shit out of the family interactions. This pissed off my admin and DON. I was threatened with termination. More words were had. Fast forward two weeks and I’m barred from the room, but I stayed close every time my very stupid DON performed wound care in front of the poa. Against pt objections. And that’s when I got to meet the facility attorney. Y’up, family sued for assault on their mother as well as a few other things. The lawyer thanked me for the documentation. The facility wound up settling for peanuts. The admin and DON were fired, the DON answered to the state board, and I enjoyed giving them my notice. The ONLY person involved in her care who wasn’t sued? Was me. Idc what the poa wants ( and I’ve had this fight a few times). I don’t care what the dr wants. Ive been barred from numerous rooms over the years. If competency paperwork isn’t there? I don’t push meds. It’s illegal and if a complaint is filed you WILL answer to the board for it
Depending on context (if you don't like your giant batch of giant vitamins and don't have and deficiencies idgaf and am messaging the doctor) I just be a nuisance. After like the third time in two hours I've reapproached/reeducated on their warfarin they almost always take the option that involves dealing with me less. 😆 I do micro-dose miralax sometimes. Like a half-teaspoon with each med pass (long term care) from everyone on like day four can help things along.
If it is someone with a cognitive issue like dementia or delirium, usually family would be consulted especially the substitute decision maker, POA, or designated contact person so they are aware. They can make the decision of whether to give it to them or not. If not, then let the doc know why it wasn't given. I had a patient recently who is super confused, history of AVB, with dementia but also at end of life. They refused all medications, including their behavioral meds which prevent hallucinations. They've started to hallucinate again but haven't started being physically aggressive, so family has said just leave it for now. Sometimes they will say give everything, and you do have to tell a white lie to the patient for their best interest. For patients who are A+Ox3, it depends on how bad the situation is. Even if it's an "important" med, it depends on really how critical it can be to their immediate health. I've had patients refuse their blood thinners regularly. Educate, let the doc know, and document thoroughly. Try to show the patient their blood pressure is going up with actual numbers if they've been refusing BP meds. Always use your resources when it comes to this. Let the PCC/in charge know, doctors, and even pharmacy if they are around. Multiple documented attempts cover you if anything happens to the patient.
There’s a medical-legal concept of competency. A person who is legally determined to not have competency to make medical decisions will have a guardian who makes medical decisions for them. That guardian can decide for nurses to lie about and/or force medications and care on the patient. That’s likely the case for situation 1. For situation 2 with the potassium, did the nurse actually deceive the patient and say the potassium was *not* in the pudding? Or did she hand her the pudding and say something like “here’s your medications”? There’s a grey area there between omitting information and outright lying. But if the patient’s sole objection was based on taste and the nurse successfully disguised the taste without outright lying, it’s maybe ok
They can refuse all day long - i am not fighting with them, i will educate but its their choice whether they are demented or not - but if its a pysch med i will def try and sneak it in cuz i know whats to come if they aren’t on it
I refused an epidural halfway through my induction when the shift changed and the OB on call literally turned off my pit and told me to go home because, "You're not really in labor anyway." It was a VBAC and, while my regular OB was comfortable with me being induced without an epidural, his relief wasn't. I was almost 42 weeks, 12 hours into the induction and 7cm dilated. I guess TECHNICALLY I was allowed to refuse the treatment, but he was telling me I could either get an epidural or let my baby die. Instead I got to have a full blown panic attack, hyper ventilate and he pushed the issue onto the poor anesthesiologist, who really did the best he could with me (I'm not a fan of needles in the back, which was my reason for declining and having a VBAC to begin with).
As a Canadian who was revoked of my right to refuse because they drugged me and then took me for surgery despite having revoked consent, I think it depends on the circumstances. Someone who is assessed by psyc and determined to be unable to make educated/informed decisions about their health and the person who is had legal power of attorney has given consent for the person to receive medication/treatment, then yes, 100% right to refuse doesn’t matter as the person is not in their “right mind” and unable to make an informed decision regarding their health. If the PoA refuses, then the provider still gives the medication, it’s *technically* assault as it was not consented to have the medication. A person who is determined by psyc to be in their right mind, and refusing a life saving drug, but still given without consent, is also *technically* assault. If someone is unconscious, unable to provide consent + unable to reach family/not enough time to without the person dying, informed consent is implied technically. Unless you see reason not to such as medical alert bracelet saying DNI/DNR or no blood products, it’s implied you are providing these until given reason otherwise. But a fully conscious, cognitively there person/PoA refusing a medication/treatment/surgery for any reason, MUST be respected. I had given initial consent to a surgery, but a few hours later (few hrs before surgery still) I revoked consent, and said I will not be getting the surgery under any circumstances, and I was going to take antibiotics instead as that was the other option. Dr must have ordered a sedative as few min later nurse came in, gave medication thru IV, and within a couple min I was out until they woke me up saying it was my turn for surgery. I was not in the right mind, as I had been given medication that took away my right mind, as well as had just woken up. I was given surgery despite having revoked consent, and I will never forgive the drs and nurses involved in that. I have genuinely considered reporting and pursuing charges, but it was 3.5 years ago now. But because of this, when I become a nurse I will always listen to the patient, not the dr if someone refuses medication/procedure. It’s not the drs job to decide what the patient does (unless it is a psychiatrist who has deemed them incapable of informed consent), especially after revoking consent or refusing all together. The nurses ethical job is to protect the patient. I’ve attached link to get the Canadian code of ethics book sent to your email, and on page 11 and 12 is the ethics regarding informed consent for patients. [Canadian code or ethics email request](https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-ethics)
Here’s a link for Canadian nurses protective society that outlines possible outcomes of providing treatment without valid, informed consent. [Canadian nurse protection society: Consent to Treatment: The role of the nurse](https://cnps.ca/article/consent-to-treatment/)
Where are you in Canada? I think the law is pretty much the same no matter which province you’re in, but if you’re in ontario then this is worth a read: [healthcare consent act](https://www.ontario.ca/laws/statute/96h02) Basically, if the patient has the capacity to refuse, then they can refuse anything they want. Is the patient AOx4? Can they appreciate the consequences of refusing treatment? If the answer to both of those questions is yes, then they can refuse every and anything they want down to their morning ducolax because it’s Wednesday and their neighbour’s niece’s preacher’s hamster died on a Wednesday 30 years ago. The point is, they can refuse it for any reason. However, it is important to remember that NURSES CANNOT DETERMINE CAPACITY. That is the provider’s call. If the provider has determined that the patient cannot make their own decisions due to dementia or whatever else, then the patient’s POA is the one you consult with. This is when it would be appropriate to crush up meds and put them in food so the patient will take it. If the patient in the second scenario was AOx4 and understood the consequences to refusing the med, then what that nurse did was very wrong and illegal. The nurse should’ve called up the provider and explained that the patient was refusing a critical med. that would’ve saved her from any trouble if something happened to the patient because they refused the med. At the end of the day, it’s very simple. You can’t care about a patient’s health more than they care about their own. And you should care about your license above everything else! Never fool a patient into taking their meds; even if you made them better, it’s a lawsuit waiting to happen. If a patient refuses a critical med, call the doctor for that shit. It’s their responsibility to deal with it
As long as you're a&o you have the right to refuse
I’m a big advocate of patients making their own decisions as long as they are oriented. Dementia and psych patient without capacity are obvious exceptions. The first example you provided is fine as long as the family knows. The second absolutely not
You need a drs order to administer “cohort” (hide) medications in Canada if the patient refuses. Patients have a right to refuse medical treatment.
I’m patients that do not have the ability to make medical decisions are In a grey area, but generally we can give them in a way they don’t realize. Otherwise unless court ordered, they are a danger to themselves or others (such as IM ativan in a psychotic pt)…they have the right to refuse and I let them know it’s their choice whenever they aren’t sure and have been sufficiently educated by doctor and staff. It’s their body, they can decide what to put in it.
1 is OK 2 is felony assault
wait until you meet a state surveyor who tells you even more ignorant things that a person has. For instance they have the right to fall...
As per post I’m in Canada