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Previous Issue's Dilemma:

My client isn't "losing it," but I think I might be 

I have an elderly client who's had no cognitive problems -- until recently. I believe his failing memory may be due to new medications his physician prescribed, but the doctor refuses to talk to me about it. Should I try to speak with him again? Give my opinion to the family? Speak to my supervisor? The family is considering putting this poor man into a nursing home, and I don't think he needs to go. 

-- Anita, RN 

Your client may not need to move, but you do

Anita, as a nurse, you're responsible for providing the best possible care for your clients. You're also their advocate to ensure their overall well-being. Therefore, in this case, you have no choice. You must ascertain whether your client truly needs to be in a nursing home before the family puts him into one. 

Our readers offer advice on how to proceed: 

• Investigate the medications.
• Start with the physician.
• Enlist the help of others. 

Investigate the medications 

Since your client seemed fine until he began taking new meds, finding out more about these drugs and how they work may be the best place to start. 

An anonymous reader writes: 

"Check all of the medications' possible side effects before the family can move the patient to a facility." 

An LPN suggests a different approach. 

"Stop giving your client the medications for a few days. Then observe his behavior or ask the family to get another doctor's opinion. The new physician may change the medications to some the patient can better tolerate, without any adverse reactions." 

Start with the physician 

We all know that some physicians can be difficult to talk to, especially if it appears you're questioning their judgment. Nonetheless, several of your peers believe you must at least try to speak with your client's physician again. 

Kathy Beaschler, RN, explains why you shouldn't hesitate to start the conversation. 

"Your patient's depending on you as an advocate, so speak with the doctor again. His perspective and priorities may have changed since your last encounter. Take into consideration this doctor's practice style and his history with your client and the family. 

"HIPAA limits you somewhat, but you still have many resources. For example, you can get an order to send out an RN for a re-evaluation with a family member present. Concurrently, notify the patient's pharmacist about the change in mental status after the med change and send him or her the current med profile. Ask the pharmacist to contact the physician with medication concerns and possible alternatives. After the re-eval, contact the physician and send him the updated medication profile along with a summary of the re-assessment. Then ask him to evaluate the patient with family present." 

Geri E. Lloyd, LPN, also offers follow-up actions if things don't go well with the doctor. 

"Speak to the doctor again. Perhaps your delivery was too passive and your findings not specific enough. Then chart what you see and speak to your supervisor or the social worker. Depending on the way your company works, speaking to the family could be considered overstepping your boundaries and illegal, good intentions aside." 

An RN also thinks that speaking with the doctor may only be a starting point. 

"Talk to the doctor again, and tell him what you've observed. If he still refuses to do anything, bring the matter up with your supervisor." 

Kathy Paradis-Payeur, CMA, LNA, concurs. 

"Be persistent in getting this physician to HEAR your concerns about your patient's well-being, dignity, respect and care. If you get no response, without hesitation speak with your supervisor about this dilemma." 

Enlist the help of others 

Other readers think you should forget about trying to talk to your client's doctor and look to others for help. 

Janet Josh, LPN, LVN, stresses the importance of being prepared before you seek assistance. 

"Go to your supervisor. But first, prepare yourself. Have the facts written concisely, such as problems, patient behavior and researched med side effects. And make sure your charting is really up there -- facts and observations."

An anonymous reader explains why outside help may be a good idea. 

"Discuss the matter with your supervisor or, if necessary, your DON. Sometimes, fresh eyes and someone else speaking to the doctor shed a whole new light." 

Donna Harrison, RN, suggests another resource for you to consider. 

"The type of medications could be causing the problem, so you need to get the family involved. For instance, they can describe the symptoms to the doctor and when they started. If the physician feels the meds are to blame, he may stop the meds or titrate them down. It's also possible your client is electrolyte-imbalanced or has a UTI." 

Sean Hess, RN, says a team effort may be best. 

"Have a care planning meeting with the other healthcare providers and your client's family to outline and discuss the changes observed. Include the physician. If the physician chooses not to attend, share the notes with him and give him a copy for his records. Tell all parties the notes will be submitted for the record. The copies should highlight all attending the meeting, those not present, the discussion and the goals discussed." 

Anita, you may feel uncomfortable about getting involved in this situation, but you must. Find out as much as you can about your client's new meds and possible side effects. Speak to his physician again. Or solicit the help of others. Your client's future depends on your actions.