1y ago

dad

The medication is a blood thinner, the patient is a competent adult not in delirium, A&OX4. There are 2 ways to see this:

Manager's and a group of doctor's POV: you are a nurse and it's your job and duty to do that. Plus, we know better than him what's good for him. These people have built their identity around working in healthcare and to them this means I have to stay in the room and make sure the patient takes the medication.

My POV: nursing is not a calling but a job. What my manager and these doctors think is stupid:

the patient is a competent adult not in delirium, A&OX4. He's old enough to know what happens if he doesn't take the medication because we have told him a number of times already. I'm not his father and I'm not ready to treat a competent adult like a child.
I have other patients and I'm not going to waste my time watching a patient silently until he decides to take the medication. I'm charting that I left the medication next to him and told him he needs it and why and that I have other patients to take care of.
It is stupid to watch a person while doing nothing when I should be working with my other patients. It's also invasive as f*ck.

I see it like this: my manager and this group of doctors are not ready to respect a person's autonomy whereas I'm not ready to ignore this same autonomy, even if it means a negative outcome. Respecting a consenting adult's autonomy means respecting his bad choices as well. I feel this group of doctors and my manager are not ready to respect any patient's autonomy.

At this moment, this is a hill I'm willing to die on. AITA?

ETA: I wrote about a group of doctors, because there are other doctors that don't give me hard time if a patient refuses his medication, they simply chart it and move on. I like working with doctors like this because I feel they don’t judge and respect the patient's autonomy as well.

64 comments

My POV: nursing is not a calling but a job.
Well, if you think of it that way and your bosses are telling you to do a certain thing, you should do that thing. If you're not doing the thing your bosses are telling you to do then maybe you're not doing your job.
Sorry if that's not what you wanted to hear, but I don't see what other reasonable interpretation there is here.
- I mean, I kind of agree here.
  I'd go full chaotic lawful if you're mentality is "not a calling".
  Follow the rules and directives as given.
  It also sounds like you are on the way out of nursing. If you're not passionate about it, the job will eat you alive without a second thought and you're going to start seeing more and more things that irk you until you leave.
  I'm also in the process of switching out of a "selfless calling" to what I hope is a fulfilling career.
  Good luck with your next steps, whatever they may be.
- The big bosses aren’t medical staff, they’re calling is not patient care, it’s profit.
  What op is experiencing is delusion in the system and burnout.
  OP is right. Document, cya, and move on.
  All these downvotes and replies seem to be from people who want to think a hospital is altruistic place of healing. Unfortunately it’s an end stage capitalism hellscape that chews up and spits out most people who give a damn.
  
  Oof this is definitely wrong. A blood thinner is one of the most important things whether a patient is taking or not. It's the nurses job to let the doctor know whether the patient is compliant not only for medical reasons but for documentation. That's outside the argument about profit in healthcare in US, that's basic medicine. What if that patient falls and hits their head? Do we need to know if they're on s blood thinner? What if they're hemoglobin starts dropping? What if they need a procedure? What tif their platelets start dropping? Etc, etc, etc.
  Don't be a dick and not do your job, that makes your coworkers miserable and puts people in danger especially in medicine. I agree with burlit being and issue and chronic understaffing but be an adult and quit or move positions if you don't like it.

This is my job. I don't want to do my job. Should I do my job?
Yes, you should do your job.
- It doesn't, you take the pills to the person, if they don't take them immediately ask them to take the pills now, if their answer is a refusal chart it and leave, if their answer is something like "I'll take them later", explain that you need them to take it now, if they still refuse chart it and leave (with the pills obviously), possibly come back later, you have other patients to take care of and can't waste time on a staring contest. But if you give pills to someone, put it in the chart that they've taken them at X time but they actually took it 3 hours later, doctors might act on that chart and cause problems to the patient and hospital. E.g. if the patient will have some surgery the next day the time they took their blood thinners is extremely relevant, the patient can't be expected to know this, you as a nurse might know, the doctor who will read the chart and decide on the procedure knows but might be acting on wrong information if you didn't watched the patient take the medicine. If the next day the doctor sees a refusal to take the medicine at the appropriate time he might choose to alter or stop the procedure, explain to the person why he'll have to stay another day at the hospital and that this time he better take the pills at the appropriate time or he'll have to stay another day, and not risk putting someone's life in danger because a nurse decided to write a random time for when the patient took the pills. Think about it this way, if you wrote that the patient took the medicine at 7 but he actually took it at 10, and he died or had complications because he was still on blood thinners during surgery, who do you think will be to blame? The patient who was not told the medicine had a specific time? The doctor who has a paper signed by you that the medicine was given at 7? Nope, 100% the nurse who wrote the wrong time on the chart will be solely liable for this.
  When I read the question I thought it's stupid, he's an adult, but the more I think about it the more it makes sense that nurses should chart only when they're sure.
  
  I don’t think the commenter claimed to work in nursing.
  If the patient won’t take it, can’t you document the refusal and move on?
  
  **
  
  You are clearly in the wrong job.

You can't chart he took it if you don't see him take it. You have to wait or chart a reason the med was delayed. Why does your ehr even have a box for "left it next to him"?
- You can put it in nurses notes, or depending on the EHR put an administration "note" in the MAR. But you have to actually put it there and then your manager will yell at you. Point is, you need to be sure they actually took a medication you documented you administered at the time you said you administered it.
  This stuff isn't "my bosses" though but "standard nursing care."
  On the point of patient's refusing meds, they're allowed to refuse. Nobody's gonna fire you for patients refusing their meds. You just document it as "refused." Now if the patient later says to the doctor that they didn't actually refuse and you just didn't feel like pushing the issue, that's another thing. Put a nurses note as to why they refused in their own words if you want to CYA on that. Doctor has to talk to them a discontinue the medication anyway if they're refusing, so you need a note.
  On a particularly difficult patient, like what you're describing, you put in the nurses notes each time you attempted to administer medication and they refused. Those type of red flag notes are always fun to see before you come on shift.
  
  This pt isn't refusing meds though. I've been a nurse a long time, only ER but still, putting in note to the ehr instead of doing one's job is bad practice. They either take it or refuse. In acute care there's no "probably took it later" option. People can refuse whatever. I tell my patients (who can leave) this isn't hospital jail but this guy seems to be talking about dumping a cup of pills and leaving.

Manager’s and a group of doctor’s POV: you are a nurse and it’s your job and duty to do that.
They’re completely right. If you disagree strongly enough, the only honorable thing you can do is quit. You are not making any kind of statement, or being “rebellious”, by insisting on doing a half-assed job. You’re simply being dishonest and providing inadequate care.
Nurses are overworked and spread too thin, but that’s not something your current behavior will fix, or even protest.
Plus, we know better than him what’s good for him.
They should. That’s their job, and what they went to school for. It is not a nurse’s place to override their decisions (except in emergencies, of course). That’s what you signed up for when you took the job. Hell, listening to your manager is a basic requirement of most jobs, healthcare or otherwise. That’s Employment 101.
Patients are often stubborn, ignorant, and it’s possible that several of them wouldn’t be in the hospital in the first place if they took their health seriously.
If you take someone’s autonomy so seriously that you’re willing to respect and tolerate their “bad choices”, that’s perfectly fine, but nursing is by no means the right job for you. It’s not the mindset that upsets me - it’s that you’re working in the worst, least compatible field possible. I hope you’re able to find something else soon.
- None! I just know it’s tough and a huge responsibility.
- This reply seems like management/ hr reply… just as salty as op.
  It’s so perfectly fine to respect someone’s autonomy there is a form they can sign- refusal of care. Explain the situation, sign form or take meds. Or, here’s another form- and there is the door. Forcing anything on a competent adult is battery I believe, no matter how beneficial.
  Like OP said, chart and move on.
  People are weird and react weird to some people. Ask another nurse to try, or ask to swap patients.
  Also, sometimes nurses do know better. They see the patient as a whole, and a lot more than the doctor.
  Also x2, managers are there mostly in a non medical (and non union) capacity, but to make sure the hospital runs as profitably as possible.
  
  This is definitely not a manager or HR reply this reads like a reply from a fellow nurse or doctor.
  This is not the field to fuck around and provide inadequate care in, to make moral judgement against medical ones. This is a field with lives literally at stake and there is no room for people who don't take that seriously. Full stop.
  
  Yeah, I am salty. Some nurses are antivaxxers, ffs. People look to them for their “expertise”, but nurses often have little or no medical education, and some don’t even accept proven medical science. I have no doubt that a few nurses have helped kill people, by reinforcing their bad decisions and ignorance.
  If a nurse knows more about a patient than a doctor, then have a conversation with the doctor. Don’t just roll your eyes and let the doctor keep making decisions that aren’t helping the patient. A lot of hospital accidents happen because of poor communication. Don’t perpetuate the problem.
  Yeah, the healthcare-for-profit system is fucked. That doesn’t address the core issue, though, which is a nurse giving themselves permission to ignore management/experts and do their job poorly.
  
  They didn't say force them to take the medicine. Just make sure they do. No one's autonomy is being taken.

With medication it tends to be pretty important to know what was taken, when it was taken and how much was taken. Leaving the meds with the pt means you can't know for sure when and how much was taken, or if anything was taken at all. And that's a problem. How's a doctor supposed to make any decision with care if they don't know for sure whether the patient has been getting the meds as ordered?
- it's easy. assume the patient took them when they were told to. if they lie to a doctor, they have to face the consequences. at least that's how I'd handle it if I was a doctor.
  
  And then when they die, their family sues the doctor for not making sure the patient took his medicine. Even if the doctor wins the case, the time and expense to fight it isn't worth it. Letting the patient face the consequences of his actions only works in a world where people accept the consequences of their actions, but we live in a world where everyone loves to blame someone else instead.
  
  Except when there are bad outcomes because the actual patient status doesn’t match up with MAR? And then it becomes the M&M case of the week.

Maybe it's not about whether the patient takes the medication or not rather you are visually confirming and documenting that they took it or refused it. Should there be a mishap or lawsuit involving this person the hospital would use that person's reluctance to follow medical advice as a defense. Just playing devil's advocate here, I'll bet a lot of hospital policies are written to protect from liability

OP, your facility should have written guidelines about what to do in this situation. Following those would be much more sensible than relying on internet randos for advice, because it won't get you fired.

Yes, you should verify whether they've taken it.

Jesus Christ. What a psychopath. You're talking about dying on a hill when it will be others who die for your belief.
- No shit. Was an entire house md episode dedicated to the patient not taking his meds when nurse left
  
  The patient AND a dog died.
- I don't think in terms of optics. I don't care if it seems degrading or feels degrading. My philosophical and moral axioms are more about results, cause and effect, reality, etc.
  Go to a homeless shelter. Or try dealing with children. There's a time and place for uplifting people, but you also have to pay attention to what's real. Think about the mental state of the person in that point in time. Learn to prioritize. Forcing a stubborn person to take pills is better than childishly clinging to ideas about personal autonomy.
  I guess if you have very little life experience, don't understand people, and haven't developed a comprehensive, holistic perspective of humanity, then I could see how this would be a dilemma for someone.
- Die for their belief? What belief are you talking about
  
  Not taking pills, or taking them improperly, can be fatal. OP doesn't care because they have a personal belief. They said that they would die on that hill, which is a poor choice of words because other people might literally die for their belief.

Isn't that a non-negotiable rule? I thought you always give patients medication on time and watch them take it. In the 2 weeks I've been an intern at a hospital, I've seen more than one person not take it or save it for later or wanting to wait for the next meal until eating the pill and then forgetting about it, or doing whatever with it. We were supposed to make sure and I don't think there were exceptions to the rule. And honestly, doctors don't tell patients if it's important to take the medications before a meal or after, or 3h before a medical procedure and if it's really important to do it right. Patients don't even know, are sick and do silly stuff. Some of them have dementia, some look alright but aren't.
It's not "their autonomy". Patients are sick, overburdened with information from doctors and suddenly 5 different medications to take. They are sometimes ill and experience pain. They're not in a normal situation where they would always make good choices. I think you're letting them down if you rely on the patients to do it right in that situation.
So don't re-invent medicine and have your own take on it. As you said it's just a job. If it's part of the job to make sure some procedure is carried out correctly, do it. Not every stupid rule is super important, but be sure the rules you don't follow aren't the ones that are 'written in blood'.
We other people also have things in our jobs we don't like. Or that are sometimes not really necessary in certain situations. If you're a professional, you just always do it right and always try to follow standard procedure.
- Could be a difference in international work culture? Or the nurses bent the truth a bit back when I was an intern there to make me do it because I was inexperienced. I work in a different field now. But I'm going to ask some of my relatives. I have family and friends who actually work as doctors and nurses.
  One thing I can tell you, being a patient at a hospital really sucks. I've been there for minor stuff like getting rid of my tonsils. And everyone in the hospital is overworked. The doctors barely have enough time to treat you properly and they're absent most of the time. And the nurses' time is even more valuable because they do all the hard work. They told me not to shower, eat, and ask for more pain meds if needed. Other than that I wasn't really able to ask complicated questions. I felt every minute they spent with me was taken away from the dozens of other patients the nurses had to attend to. And most of the other patients had proper medical conditions. So I just took the random pills they gave me without questioning. I was an otherwise heathy patient about 30 back then. And it was quite an ordeal to find out why they keep me there and when I was going to get released. Also the anasthesia sucked and stuck with me for the entire day. And the other patient in the room sucked because he slept for like 4 hours and was in pain again and would watch stupid morning television with sound from like 4:30am. I mean I was treated properly, everything turned out great and especially the nurses treated me really well within their time limits. But except for the meals, which were surprisingly good for hospital food, everything was just a sucky situation for me. I don't know where exactly I was trying to go with this... My situation worked out well because of established standard procedures. I don't hold a grudge against nurses. They are very well trained professionals here. And they really get out of their way to treat you kindly. And sometimes that is all you have left in a sucky hospital day as a patient. Even I (with a minor sickness) completely relied on them because nobody had the time to explain things to me so I could make my own decisions. I guess all I want to say is, please do your job properly, whatever this is, we people rely on you.

It is a job and at a job you follow instructions you get even if you think they are stupid.
- hey, fellow german, I think we both know why this shouldn't be the norm.

Seems more like a question you should direct at your manager and coworkers, but you know you won't like their answers, so you're asking here where we lack context lol.
- I'd ask you what hospital you work at.
  No reason.

Work in a hospital, not a nurse. Usually nurses bring meds with water and hand then to the pt. They either check on the lines, pumps, etc or chart for a minute or two. Then ask if there's anything they need. By then they usually have taken the meds and the RN leaves. There's only so many times you can tell a pt why they need to take them. I work with psychiatric pts and usually, if they refuse the RN just notes that they refused.

Imo it depends on the patient. If the patient says they take the meds but their signs - vitals, telemetry, routine labs, PE, etc show otherwise - then it’s your responsibility to confirm or deny patient medication adherence.
I’d like to say a functioning healthcare team means that the top level providers will trust their nurse’s judgement about the patients they are in charge of.
But at the end of the day this is about treating patients and ensuring that a standard of care is met. Part of that standard is allowing for shared decision making, non paternalistic care, etc.
But again, it is your responsibility to know what is happening with the patient. It’s not really that you’re forcing the patient to adhere, it’s to confirm if they take it or not.

If not taking medication is a frequent problem with them, I'd call for a psych evaluation. Could be as simple as the medication is making their mouth itchy or stomach hurt and they aren't explaining that or connecting the dots.

What hospital do you work for?
I ask because I want to know which one to avoid should I ever need to go.

What if they hoard the meds and then take them all at once?
- Then congrats to this competent adult, they have probably killed themselves. That's their choice to make.
  To OP's point it's not their job to prevent someone from doing something stupid but rather to educate and provide an alternative. You can lead a horse to water and all that.
  
  It is literally their job to ensure the patient has taken the medication prescribed to them as directed by the doctor. It's a controlled environment. It's a hospital.
  
  They're in your care though, you need to CYA and be able to document if they took their medication at the correct time.

I'm not a nurse, but I think the way you're charting is the correct way to protect your license. If they're A&Ox4 then there's probably not a legal/regulatory reason to sit and watch them, but it's also probably not out of bounds for hospital policy to require staff to observe and confirm any intervention (including meds) provided while under their care.
Now, whether they're going to take into account how much cumulative time/work that adds to the nurses and then staff accordingly is another story... (Hint: they won't)
- I don't think so, I mentioned this scenario in another answer, imagine they took the pills to the patient at 7, the patient only took them at 10, but the chart says he took it at 7. The next day the doctor looks at his chart and decides enough time has passed and a surgical procedure can be done to the patient. Because he took it at 10 that's not true and because he's on blood thinners there are complications and the patient dies. Who's legally at fault? The doctor has a paper trail to explain why he did what he did, this leaves the blame entirely in the hands of the person who signed a paper saying the patient took the pills at 7.

OMG this community gives me brain health issues, I'm blocking it

So what happens if they don't want to take it, or want to take it "later"? Are you expected to force-feed them? Call security? Hold yourself hostage until they change their mind?
I'm with you on instinct, but I have no idea what the regulations are like in healthcare.
my manager and this group of doctors are not ready to respect a person’s autonomy
This is why I hate hospitals. I'm there because I need medical help, not because I am incapable of running my own life.
- Eh, if you're in the hospital, do what you're told. If you don't want to listen then just fuckin leave.
  Waffling in the middle is a waste of everyone's time.
- If you need medical help... why aren't you accepting that help? Medication is often a part of that help. If you have problems with the medication, you should talk with your doctor, not act like a petulant child.
- If a patient doesn't want to take it, they just say they don't want to take it, no one is force feeding people or calling security. Patients refuse medication all the time for many different reasons. In this example, the nurse should just document the patient refused and why, notify the doctor what happened, and continue on with their work. Not stand there in an hour long staring contest until the patient takes it.
  It's very important the medical staff know what things you have and haven't actually taken while in the hospital (and before you got there too). If it's a medication you really need, your doctor will probably come and explain why refusing is a bad idea. If people don't like the plan, don't want any treatment, or don't want to stay in the hospital, they can just walk out and leave. It's a hospital not a prison. Your doctor may just ask you to sign something just to document they explained to you why leaving is a bad idea.
  
  It sounds like you're on OP's side to "chart it and move on", which makes sense to me. I don't quite understand what more OP is expected to do here.

64 comments