The Right to Refuse

I have started nursing school (hence the reason for less posts) and am learning things that I hope to be able to use in my work with individuals with intellectual disabilities. One of the things we talked about in class recently is the right to refuse aspects of care. A person has a right to refuse treatment, a right to refuse medications, a right to refuse exercises, and so on. There is a second piece to this, though, that we don't always address. When a person refuses something we think is in their best interest (based on information derived from science, evidence, and education), we have an obligation to discuss with them the potential consequences of their refusal.

In my undying love of using the exact right word, I think a better word would be "declined." The person didn't refuse my offer of going out to exercise, she declined it. The intent of declining something offered seems more polite. Most of the time, when I have been refused, it was polite.

Anyway, last week at one of the group homes, one of the men declined his medications. He absolutely has this right. Our job, then, is to return a few more times after waiting a bit, to see if he will change his mind. If he still declines, we call the doctor and that's that. It is important to realize, though, that missing some of these medications could cause him discomfort or harm.

In this case, staff asked my opinion. I told them to find out the function (or why) he was declining. The answer was that he wanted something he couldn't have (but that often causes him problems should he have it) and was displaying his discontent by controlling something he could control. The team working with him that day discussed which was the area of most concern - that he not receive the small item he wanted or not take his medications. We decided that day to give him the item. He took his medications and his mood turned around for the rest of the day.

Another staffer a few days later nicely suggested another way we could have gone. She said that when this fellow declines medications (or shower, or chores), she explains to him the consequences of his actions. The last time he would not take his medications, even though he was very angry about not being able to have something that belonged to someone else, she was successful in getting him to understand that he wants to feel better and control his actions better and that the medications help him with that. He was still angry but he did take his medications.

So chalk that up to about the 42nd mistake I have made this week (giving him the item). A better approach, as described in my nursing class and by my wise co-worker, would be to realize that the individuals we work with are smart and we can discuss with them the possible consequences of their choices. That would be another step in treating them equally.