My elderly patient stopped taking his medications every 2nd day. What should I do?

My wonderful step dad was taking blood thinners and medications that gave his heart the priority for life. He was bed ridden and after a couple of years (before his 95th birthday), he asked my mom if she would be okay stating that he wanted to stop his medications. She assured him she would. His mind was good, he was just tired and bed ridden gives a different degree of pain from the lack of motion and weight bearing movement. He only took the arthritis pain medication. We thought he would be gone in a week and it was 3 weeks. He was humorous when every morning he would “ask” mom, “Am I dead yet? I was ready last night?” He was peaceful with the last 3 days being him sleeping all the time. Mom called the pastor and he did a bedside communion as soon as he went off the medications and it was precious for all of us. We didn’t know if he would die or have a stroke or have a heart attack and continue living…..we were blessed that he passed peacefully.

"He seems completely able to discern the risks..."

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?

I know you don't want to go against the patient's wishes. It's very hard to care for someone every day. Please talk to the doctor and the family and maybe call a meeting. Is the patient suffering from side effects? Is he capable of making this decision? Suffering from cognitive impairment?

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.

“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.”

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.

It could be because of money. Or side effects. Or depression. It is a person's right to refuse medical care including medicine. If his mind is intact, write the alphabet on a piece of paper - have him point to spell words. Or write out those options, is the reason you stopped your meds a: money, cost b: side effects, how it makes you feel c: you have given up hope etc. Have him point. Outside the box people!

Hi! Please listen to his family. They want what’s best for him.

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.

Has he had any recent blood tests to see assess the effectiveness (or lack thereof) of taking his medicines on alternate days? Perhaps with slowing metabolism, every other day will turn out to be sufficient.

I so respect your caring principals and agree that when fully capable it’s a patients decision as to how they want to live or die. I also respect that you recognize a dilemma here and the fact that he is refusing every other day seems like evidence of either not remembering or understanding the ramifications or a fluctuation in wishes or uncertainty in what he really wants. I think the plan you seem to be following is a good one, making sure he has his medication until the family and his doctor can be sure he knows and understands the ramifications and you can all be sure he knows what he wants. You obviously have found a way to communicate with him but it can be especially hard with such a big and important concept to be sure and GBSandRA has a great idea if you don’t already use the method, to use writing as a way either the alphabet or un-suggestive sentences as choices because it tests his comprehension as well as his wishes which might be helpful for you. It sounds like you are taking great care of him and really care about your patient, I’m sure the family appreciates how lucky they are to have you.

Has his stroke affected his cognitive ability otherwise, i.e., can he communicate in writing or by pointing? Elaborating on suggestions already made?  If so, use that as a method, simplifying the questions and providing a range of answers so that he can just point to one answer,

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

IMHO, I ask the question. Do you ever think that maybe the patient is within his rights and there maybe a good reason for not taking his meds? I, for one, have not had a stroke, have NO one to answer to and as soon as my husband passes, I am giving up my meds! I will NOT live the life that the old people are suffering to live in the HOME. I think it is ludicrous to live to be 100 and older. You don't even know who or WHAT you are and if I had a patient that did not want to take his medicine, I would respect his rights and let the family know that perhaps he wanted to go. Forcing a patient to take meds by sneaking them into his food is immoral and against nurses ethics.
Just me two cents worth.
Temper