Ethical considerations?

Shadowfax and Scalpel have interesting posts up about the ethics of medicating psychiatric patients without their consent.

Once, as a student nurse extern working on a medical floor, I had an interesting case.

A woman in her thirties was admitted for brittle diabetes; she had a tendency to alternatively pass out from low blood sugar (once on a heat grate in her house, resulting in bad burns to her legs) or be hot, dry, and miserable and in DKA. She lived at home with her family, but her parents were away in Europe for weeks, and her brother, who also had diabetes, was looking in on her, found her unconscious, and brought her to the hospital.

She was, as my mom would say, "half a bubble off plumb." (Frankly, I wasn't surprised--I would be too if my blood glucose was regularly around 17.) She was a little slow in her speech, she was emotionally labile, had a strange, flat affect, and had a few other issues, but was very sweet once you got to know her. She looked a little like Courtney Love coming off a bender. My kind of gal. She also had a little hint of a goatee, probably from metabolic problems related to her diabetes.

The decision was made to admit her to psych after she was medically stable. The psychiatrist wanted us to administer a B-52 (benadryl, ativan, and haldol), telling her it was insulin, then wait ten minutes to make sure it was working, and then he would tell her that instead of going home, she was going to be put on the psych ward. And then she would pass out from the meds and wake up on the psych unit.

I felt very conflicted about this. First off, there was no way she was going to believe that the injection I was giving her was insulin--it was a huge amount of meds (around 3 ccs as opposed to the relatively small amounts of insulin we had been giving her), it was an IM, not a SC, injection, and, those meds STING like a bitch, whereas insulin usually doesn't. Also, she was calm and alert and oriented; I felt bad about flat-out lying to her. I also was a starry-eyed nursing student, ready to use my therapeutic communication skills.

My preceptor also did not feel comfortable with it. She basically called the psychiatrist a chicken and stated that she refused to do his dirty work for him, and that if he wanted to lie about the shot, that he should do it himself.

We ended up compromising. We took a couple of male nursing assistants into the room with us, and I sat next to the bed (apparently I was the only one on the floor whom the patient trusted...ugh, guilt) and explained to her that I wanted to give her a shot to help her stay calm and cool while we all talked a little about her stay at the hospital. Her anxiety level immediately shot up and she said, "But I'm going home, today, right?" I told her that was what we would discuss. She started moaning, "no no no no no no no..." so I used my student nursey skills and said, "You seem very upset. Would you like this shot to calm down a little so we can talk?" After a few minutes, she agreed, so I stabbed her in the butt with the needle.

A few minutes after that, the psychiatrist came in and started to explain that we wanted her to stay a little longer, that we needed to do some tests to see what was causing her "hairy face," and that he wanted to transfer her to a floor where her "state of mind" could be evaluated "for a couple of days."

She LEAPED up off the bed and grabbed the shrink around the neck, screaming "NOOOO I WANT TO GO HOME I'LL KILL YOU I HATE YOU I HATE YOUUUUUUU!"

So much for the B-52. We wrestled her down to the bed, and held her there until the meds started to work. As she was drifting off, she said to me, "You hate me, don't you."

I replied, "No, I don't. I like you a lot."

She said, as her eyes shut, "You even like...my hairy...face?"

I assured her that I did. After she was asleep, she was transferred to the psych ward. I felt kind of bad about the whole thing for quite a while. But what else could we have done?