What if a Patient Won't Follow My Advice?

Question
What is a nurse's responsibility when a patient wants to do something that is unsafe?

Response from Carolyn Buppert, MSN, JD Healthcare attorney, Boulder, Colorado

The nurse who asked this question provided the following example: A patient who was admitted to the hospital because of increased seizure activity leaves the unit to go outside to smoke, against the nurse's advice.

The nurse's responsibility is to give the patient evidence-based advice, to explain the rationale for the advice, to advise the patient of the consequences of not following the advice, and to give the patient a time frame -- when the patient should do whatever is advised. The nurse should then document the advice given and the patient's response. What happens next depends on the nature of the advice and the risk. For example, if the patient with increased seizure activity goes outside to smoke, against advice, the nurse has no responsibility or authority to detain the patient. However, if the patient is threatening to jump out the window or otherwise hurt him- or herself, clearly the nurse's responsibility moves to a higher level: Call for help and make every effort to dissuade the patient from jumping.

Usually, the situation is somewhere between the extremes of these 2 situations. For example, a patient needs some sort of follow-up (diagnostic test, consultation from a specialist, medication, or lifestyle change) but doesn't comply. Then, the nurse's responsibility is to persist; that is, attempt to find out why the patient isn't complying, urge the patient to comply, repeat the explanation of the necessity for compliance, continue to teach the patient, and enlist other healthcare providers to reinforce the advice. The level of assertiveness of the nurse must be titrated to the severity of the consequences if the patient doesn't take the nurse's advice.