Out of the blue this past week, my elderly patient (who lives at home, and I am a live-in male nurse) stopped taking his - heart, blood thinning, diabetes, antidepressant- medications on every odd day. So one day he takes it, the other he rejects it.
He seems completely able to discern the risks, but I can’t understand what he is saying because he has a speech impediment due to a stroke.
His family says to break the meds and mix them in with food, but I feel this is against my caring principles as the first rule is always respect my patients and I don’t want to lie to him.
What is your take on this? What should I do?
Looking back I wish I did more to help my dad. He also refused his meds and let him be and it was a fatal mistake. I still wish I did what this family is asking you to do because then maybe my dad would still be alive. The regret and guilt I feel is still very painful.
I have been giving him the medication in food, but I feel like I am betraying him.
I would wish to respect his wishes and maybe the doctor can provide a better solution to this issue. So sorry to hear about your dad. My mother was a terminal cancer patient when she rejected life-prolonging treatments and I supported her fully. It all depends on the quality of life one has left, and I strongly feel it’s an individual choice.
If you can’t understand what he’s saying, what makes you think he knows what he’s doing? I guess he also can’t write what he wants?
If he wants to die, wouldn’t he be rejecting all the medicine, every day?
Maybe he’s very unaware of the risks he’s taking. If he can’t make decisions, the family will make good decisions in his best interests: follow the family please.
Look OP, here you posted his medicines:
“heart, blood thinning, diabetes, antidepressant- medications”
Many of these have severe consequences if you stop cold turkey (taking every other day IS kind of like stopping cold turkey = in other words, it is kind of like suddenly stopping, instead of slowly tapering off).
If he’s depressed, and takes anti-depressants every other day, he’ll get more depressed/suicidal. A suicidal person won’t make good decisions.
Diabetes…etc.
Heart…
These are all serious medicines.
Well, there's the answer to the question of whether it's okay to give him the medications covertly. NO!!! Don't. You cannot give a person who has mental capacity - i.e. understands what he is doing and appreciates risks and consequences - any form of treatment or medication without his consent. It's not just unethical, it's illegal.
Are you a qualified nursing professional? If so, you should already have a code of conduct to consult. If you don't have a line manager (i.e. if you are self-employed, paid by your patient or his family) to take instructions from, you can still follow protocol as laid down by your professional body.
Meanwhile: document. I assume you're keeping MAR charts anyway? So you should have a written record of when your patient is taking his medication and when he is declining it. You can add observations of the apparent reasons for refusal. If you can't understand what he is saying about it, you can suggest a list of reasons and wait for him to agree with the one that applies.
Approach it like twenty questions. For example:
This is your medication Mr Patient and I understand that you are declining it. It is your decision which of course I accept. However I need to record this, and it would be really helpful if I can also understand why you don't want to take them.
Is it because...
You are worried about the dose?
You are feeling sick?
You find them uncomfortable to swallow?
You are not confident that I am giving you the correct tablets at the correct time?
And so on, working through what seems likely to you based on your knowledge of this individual, until you come to "you just don't want to?"
You must also report the refusal to the prescriber. The one you mention which would really worry me is the anti-depressant - skipping doses of these does nasty things to brain chemistry and is not good. Is your patient refusing all of the medications or only some? Are you offering them one at a time or all together?
When a person has mental capacity but difficulty with communication, it is up to you to find ways to help him communicate. Have you been with this patient for long?
When my father was intubated and couldn't speak, I created an answer board, with photos as much as possible, but also a list such as
Cold; need another blanket
Thirsty, need swab (disposable oral swabs)
Bedpan (with a cutout photo of a bedpan)
Nurse (with a cutout photo of a nurse)
Call (usually someone in the church, with a list of names from which to choose)
I attached a pencil with a string to a clip board, so Dad could also write if he wanted to. A small and easy to use pad was also attached to the clipboard.
I had a few dozen options, so Dad could point to the one(s) most appropriate.
E.g. answers such as:
1. Medicines don't seem to help.
2. Medicines create side effects.
3. House (a) checked recently, and okay (b) any issues? snow needs removal, etc.
The biggest problem though was that staff (nurse, speech therapist or CNA) picked up the board when treating him, putting it somewhere out of his reach, and compromising his ability to communicate, probably w/o thinking that removing his only means of communication wasn't appropriate
This means he might be suicidal. A suicidal person doesn’t make good decisions.
The family has his best interests at heart. They would know, I think, what’s the best way forward. Worth saving his life, or not.
Call this patient's DOCTOR for advice. And do NOT do anything that violates your own principles or code of ethics.
Also, take into consideration that your patient has a speech impediment from a stroke which likely means he has DEMENTIA caused from this stroke which means he is not able to make rational/logical decisions, nor are you able to use 'reason' or logic WITH him in order to arrive at a satisfactory conclusion with respect to him taking his meds properly or being given his meds properly.
Good luck.
Just me two cents worth.
Temper
Now the only argument in such cases is to be had is that: can he exert his will or is he outside mental faculties and if so, a court should mandate that someone else takes over their decisions. Anyway, even then, one can argue that no one is to take over anybody‘s body without consent or by sneakily drugging them
As his nurse, do you have ability to talk to his doctor? If so, I would not hide meds in his food without asking doctor how to handle this issue --- and if dr tells you to do that, ask him to confirm via writing so there are no questions later on.