A little insight....... (long sorry)

[Nurse Lulu]

HI guys! I have been a nurse for almost a year (passed last Feb), and on the unit since December. I got in my first BIG fight with a doc this morning, wondering what you think....

pt was s/p c-section where her bowel was nicked, and long term untx htn, so she came to IICU. Her baby is still in NICU on vent, cocaine, ETOH t/o pregnancy/life. However, pt a+ox3 NOT acting like d/t (see it a lot). Pt states I AM LEAVING! I don't like x,y,z and I am going home! Tried to reason, pt started putting on clothes, saying she was out. Asked charge nurse about IV/foley, she said if you think she is going to leave with it in or pull it out, d/c it, so I did. Told her doc had to see her (per policy ICU resident) and nursing supervisor. pt states "he better hurry, I am not waiting." Ok......

It is 0700 called resident stated "call the intern I don't have time for this crap.."called the intern "I am not on call anymore." I asked well who is? "I don't know" Well what is their pager? "I don't know." "Call the operator." I did she said you are on call.....recalled resident who stated "I am not on call anymore." All this why trying to keep the pt in the room:angryfire

Called the supervisor, who in turn makes them come (which neither is happy about) pt already off monitor, with clothes on, already called ride, etc. Resident makes comment about stupidity and wasting his time in front of pt, then orders ativan 3mg IV which pt states she does not want, blows up when I tell him IV pulled. Then tells pt she can't see her baby if she leaves (hi you can't say that) and orders it IM. I do not think this is appropriate (chemical restraint) for someone clearly wanting to leave. "I am sorry, I am not comfortable with this order, if you want you can give it yourself." Dr. states he thinks she is in DT's. "Well you could petition her..." Pt states she is done and is going home. Put AMA paper in front of her (which she signed) and started heading for elevator.

Then turns to me and says "I hope you are happy, it is your fault she left." "You should have given her the damn ativan." As he pages OB supervisor. I tell nursing supervisor what's up, as I am on the phone he is still hissing at me (I finally said I will be with you in one moment.) He smiles when he hands me the phone for the OB supervisor, who just states let the attending know (he looked disappointed). grrr........ My manager showed up for the last part and said don't worry but, I am still nervous. Did I do the right thing? Now it is in risk management, and god knows where else. Is there something I could have done differently? Would any of you given the ativan? I don't know, keep rep-playing it don't know what else to do......CAT

[EmmaG, RN]

Yes, you did the right thing. No, I wouldn't have given the Ativan. Yes, the "doctor" was an idiot.

(and idiots like this are why I HATE teaching hospitals)

[NotReady4PrimeTime, RN]

Great outcome, cat84! How empowering to be so supported. Keep up the great work!

[al7139, ASN, RN]

Hello again,

I am glad that you have the supprt you deserve after that incident. I do have to comment on a poster who stated something to the effect of "I hope we have clearer guidelines and docs will start writing clearer orders on pts they feel should stay in the hospital"

Since nursing school, it has been my understanding that a doctor does not make the determination as to whether or not a pt is incompetent to make their own medical decisions, and that nurses should not follow orders to chemically or otherwise restrain a pt against their will unless the pt has been deemed BY A COURT OF LAW to be mentally incapable of making their own medical decisions (for their safety or potential harm to others), so unless I have a legal medical guardian who I have consulted with prior to giving a med, I will never prevent a pt from leaving AMA. I can't make someone get the treatment I know will help them, it is their right to refuse.

Amy

[David's Harp]

Wow - good on you for your grace under pressure!

I can't picture any of the flock of residents on my floor wanting to be bothered with someone who wants this badly to bolt. There's usually someone who can get that person's bed within the next couple of hours anyway, so if the person is with it it's a matter of treat-OR-street.

This is a good example for me in the likely event that it comes up, because by my understanding had you forced the IM Ativan it would've been your orifice on the line, legally speaking.

-Kevin

[patwil73]

Hello again,

I am glad that you have the supprt you deserve after that incident. I do have to comment on a poster who stated something to the effect of "I hope we have clearer guidelines and docs will start writing clearer orders on pts they feel should stay in the hospital"

Since nursing school, it has been my understanding that a doctor does not make the determination as to whether or not a pt is incompetent to make their own medical decisions, and that nurses should not follow orders to chemically or otherwise restrain a pt against their will unless the pt has been deemed BY A COURT OF LAW to be mentally incapable of making their own medical decisions (for their safety or potential harm to others), so unless I have a legal medical guardian who I have consulted with prior to giving a med, I will never prevent a pt from leaving AMA. I can't make someone get the treatment I know will help them, it is their right to refuse.

Amy

Actually doctors can make the determination to "hold" a patient they feel is imminent danger by walking out of the hospital. However, once that determination is made then they have to contact the Mental health Professionals who must arrive within 4 hours and determine if we are going to continue an involuntary hold.

The problem occurs is that doctors will "feel" a patient is at risk and order say a one to one sitter to watch them. They will discuss the need for inpatient treatment, but they will not write an order that says "Patient is at risk for self-harm. If they attempt to leave hospital restrain and call immediately so we can begin the involutary hold procedure". They simply expect us to "know" that is what they meant.

I can read our policy pretty clearly - if the patient presents as A&O, does not make self harm threats or threats against another - then I don't consider them to be an imminent risk and they can go - regardless if they are a one to one or not. However, if the doctor has written an order like the one above - I will call security to stop the patient, and if they can't i will call the police and inform the doctor. We have a duty to protect our patients even from themselves, but the risk has to be imminent in order to do so. Even if you "know" the patient is going to do something stupid, unless they say "I'm going home to kill myself, my ex-wife, etc" you can't stop them.

So anyway, the doctor can start the hold, but you are correct in that ultimately it is the MHP that will determine if we continue to do so.

Hope this clarifies my position,

Pat

[Danycejw2006]

WOW. Cat. You absolutely did the RIGHT THING!

The pt. could have sued you and the doc. for giving that ativan.

It's your license. WHENEVER you do not feel comfortable administering an order....you ALWAYS have the right to say no. It's better safe than sorry.

Trust me, the doc knew you were right. He/She is trying to save his/her own butt by placing all the blame on you.

Way to go. It's nurses like you that make healthcare safe and effective!! GOLD STAR!!