Smoking on Oxygen, a Third Shower Refusal, and a Coworker's Advice
Mrs. Loretta Pitre, 82, is alert and oriented and walks with a walker. She is on 2 L/min nasal cannula around the clock. It is 2:00 p.m., 48 degrees with a stiff wind outside, and she wants to go to the designated smoking area now. "I've smoked for 60 years - you can't stop me." She has also refused her shower three days running, saying the shower room is cold. A coworker tells you, "Just chart that she refused everything and let her go. It's her right."
1. Mrs. Pitre wants to smoke while wearing nasal cannula oxygen. What do you do?
Read the worked answer
Do not allow smoking while the oxygen is in use, and do not physically block her or take her walker.
Immediate steps:
- Tell her plainly why: "Oxygen makes fabric and hair catch fire fast. I can't take you out there with your oxygen on."
- Do not turn the oxygen off yourself to make the trip possible. Oxygen is an ordered treatment; only the nurse stops it.
- Notify the nurse now, while she is still in the building and calm. This is the nurse's conversation: whether oxygen can be discontinued for a supervised period, whether the facility policy permits a supervised smoke, and whether a refusal form is needed.
- Offer the alternative she can actually have: a later smoke when the nurse has decided, or a nicotine option if one is on her care plan.
Why this is not purely "her right":
- Fire is a hazard to every resident on the unit, not just to her. No facility allows open flame next to an oxygen concentrator or cannula.
- Her autonomy is real, but the mechanism for exercising it against medical advice is the nurse and administrator, with documentation - not an aide deciding at the door. Blocking her with your body is also wrong; it escalates and can end in a fall with a walker.
- Note the cold and the wind: even with the oxygen question settled, a frail 82-year-old with a walker in 48-degree wind needs a coat and a check-in, not a solo trip.
2. She has refused her shower three days in a row. How do you handle the refusal?
Read the worked answer
Respect the refusal, but do not stop at the refusal.
Honor it: she is alert and oriented; a competent adult may decline a shower. Do not force, threaten, shame, or strip her. Do not tell her she "has to."
Investigate it: she has told you the reason - the shower room is cold. That is a fixable environmental problem, not a stubborn personality. Options:
- Warm the room first, or move the shower to a warmer time of day.
- Cover her with a bath blanket for the walk down and have a warm towel ready.
- Offer a bed bath or partial wash as an alternative that meets the hygiene goal without the cold room.
- Escalate the cold shower room to the nurse as a building or unit problem, because other residents are being bathed in it too.
Document specifically: "Refused shower at 2:10 p.m.; stated the shower room is cold; offered warm room and bed bath; declined; partial wash of face and hands completed." That record is what supports both her rights and your care.
Three days of refusal with a stated, correctable reason is a care-planning problem. Three days of "refused" with no action looks like neglect on paper.
3. Your coworker says, "Just chart that she refused everything and let her go." How do you respond to the coworker, and what do you actually chart?
Read the worked answer
Do not chart an event that did not happen the way you wrote it.
To the coworker: keep it short and unarguable. "I can only chart what I actually did and saw. I'll write what she refused and what I offered."
Why "refused everything" is both dishonest and dangerous:
- It is vague. It does not say what was offered, what she said, or what care was given. A nurse reading it cannot tell whether the resident is declining or whether nobody tried.
- It can be wrong. If a partial wash was done, "refused everything" erases real care you provided.
- Charting to fit a coworker's version is falsification. It is a certification and employment risk, and it hides a resident's actual condition from the next shift.
What you chart:
- Time, what you offered, her exact words in quotes where useful, what care was completed, who was notified, and that the oxygen-and-smoking question was referred to the nurse.
- Only your own observations. If the coworker wants something charted, the coworker charts it.
Also report the pattern, not just the incident: three days of refusals plus an oxygen safety conflict is a change the nurse needs to see, and a care conference may be the real answer. An aide who documents accurately and escalates is doing the job; an aide who writes "refused everything" and walks away is not.