"I Have Power of Attorney"
Mrs. K, age 88, is in a rehab unit after a fall at home. She is alert, oriented to person, place, time, and situation, and answers questions appropriately. Her daughter holds durable power of attorney for both finances and health care. Mrs. K has declined her shower three days running and says, "I don't want a stranger looking at me." This morning she also waved away the cup with her blood pressure pill and said she did not want it. At 10:00 a.m. the daughter arrives and says, "Make her take that pill and give her the shower. I have power of attorney, so she doesn't get to refuse."
1. Mrs. K has refused her shower three days in a row. What is the appropriate response, and what are you not allowed to do?
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Her refusal stands. She is oriented to person, place, time, and situation, and she is giving a reason - being seen by a stranger. A resident who can make and express a choice can decline care, even care that is good for her and even when a family member disagrees.
What to do instead of pushing: treat the refusal as information. Ask what would make it possible - a same-gender aide, a bed bath or a partial wash at the sink, a gown or towel draped for privacy, a different time of day, a shower chair if fear of falling is underneath it. Offer, then accept the answer. Reoffer later in the shift and the next day; refusal today is not a permanent decision.
What you must not do: do not undress her, do not wheel her into the shower against her protest, do not threaten, bribe, or shame her, and do not skip the hygiene she does accept (face, hands, oral care, peri-care as she permits).
Then: tell the nurse each refusal so the nurse can assess what is driving it and talk with her and the family. Document the refusal, the reason she gave in her own words, what alternatives you offered, and the fact that you notified the nurse. Documenting "refused shower" with no detail makes it look like noncompliance instead of a modesty issue that could be solved.
2. What do you do about the refused blood pressure pill, and where does your role end?
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You do not administer medications and you do not decide whether a dose is held, repeated, or replaced. What you do is report the refusal to the nurse immediately - not at the end of shift - because a missed blood pressure medication is a clinical decision with a time limit on it.
Do: take the cup away and secure it per your facility's policy (do not leave it on the bedside table where she or a visitor could take it later or where another resident could reach it), tell the nurse right away with the details - which medication, what time it was offered, exactly what she said - and note it in the record.
Do not: hide it in food or drink, coax her by saying it is "just a vitamin," promise it will not matter, or tell the daughter you will "make sure she gets it." Concealing medication in food is a serious violation of her rights, not a workaround.
The nurse's job, not yours: assessing why she refused (side effects, swallowing trouble, fear, cost, a decision she has thought about), determining capacity for this specific decision, and contacting the provider. Your job is to make sure the refusal is known fast and is charted accurately.
3. How do you respond to the daughter's demand, and what do you document about the conversation?
Read the worked answer
Move the conversation out of the room and out of the hallway, then acknowledge the real fear: she is afraid her mother will fall again or have a stroke, and she thinks she is protecting her.
Be clear about the limit without giving legal advice: "I understand you're her power of attorney, and I know you're trying to keep her safe. I can't force care on her, and I can't change her care plan. Right now she's able to understand and tell us what she wants, and she's saying no. The person who can talk this through with you is her nurse - I'll make sure she knows you want to speak with her today."
Avoid: do not debate whether the POA "counts," do not say "your mother is competent so you have no say," do not share her diagnoses, medications, or clinical details with the daughter without knowing what she is authorized to receive, and do not promise to try again with the shower as a way to end the conversation.
Document: time, who was present, what the daughter requested in her words, what you told her (that you would refer her to the nurse), that you made the referral, and Mrs. K's own statements about what she wants. Then actually hand it off to the nurse - a documented referral that never reached anyone protects no one.