[RiverNurse]

Hi all,

I have something that happened so quickly the other day that it just happened before I could even think about it - or the ramifications.

I had a patient that had an EGD in the morning and had been back on the floor for several hours - alert and craving a cigarette (nicotine patches weren't doing the trick). He said he wanted to leave the floor to smoke. I told him I thought he should wait. He said he was going to go anyway. At that point (I am in orientation) I went to talk to my preceptor about this pt's insistence on leaving, and also told my nurse manager. I asked my preceptor to try to detain the pt as the pt was next to the elevator by this time. My manager said, "Wait, let me think about it." She walked off. I thought she was going to come back, so I went to talk to the charge nurse as well for input. She just said that the patient couldn't leave. My manager never got back with me. I thought of AMA, but wasn't completely sure and wanted to know how to handle this - I just didn't know how at that moment.

In the meantime, my preceptor talked to the pt. The pt said he could do whatever he pleased and that he was an adult. He left the floor to go smoke. My preceptor said that there was no way to stop the patient other than to restrain him - and the patient said he would be returning - which he did.

We are on a non smoking campus - so that would have meant that the patient would have had to cross the street to smoke. I documented all of this in the progress notes and notified the doctor. The doctor said that the patient was AMA and that he should have signed out as AMA before leaving. I thought of that - but thought that would have equated to a "discharge".

Um... I know I didn't learn this one in orientation. I really hope I don't get written up for this one.

Please - seasoned professionals - tell me I'm going to get better at this!!!!!!!!

Argh. In my early days of school - my "fantasy" was to be a GREAT nurse... not just an adequate nurse or even a 'good' nurse - but a real lasso loopin' popgun shootin' kick butt and take names kind of nurse.

I'm still waiting... LOL...

Take good care,

Shawna

[cardiacRN2006]

Originally Posted by slangdell

He left the floor to go smoke. My preceptor said that there was no way to stop the patient other than to restrain him -

You cannot restrain someone for wanting to go smoke. That would be about the biggest mistake that you could make. You would be fired, sued, etc, etc.



Just let him leave and he will come back. Document that you explained all the risks, and that he understood.

You could try to have him sign an AMA form, but honestly, he just needed to smoke...


We can't break them of an addiction overnight. And, the nicotine patches don't work that well (so I hear).
I would tend to think that he's under a lot of stress and smoking helps relieve that.


Some will say that if he doesn't want to participate in his proper health care then he should go AMA. But addictions aren't rational.


Blah, blah. He just needs a smoke.

[Spidey's mom]

I agree - patients are not prisoners.

Our patients go outside to smoke sometimes . . . the docs are ok with it. Depending on the reason they are there of course . . . .

You cannot force someone to sign an AMA form either . . . .

(and I've never smoked and hate cigs).


steph

[yanski]

We always care for our patient, we do everything just to make sure that they are in good care. In that certain scenario, did the doctor barred him not to smoke. If not, you should respect her decision, as what other said it is not good to detain someone who want to exercise his right to enjoy himself. Even it is bad to our health but he already knew that thing that's why he leave for that place for some reason that place is a smoke free. But in a certain reason if the doctor said that he must not going to smoke so, it is your duty to advice or detain just to avoid smoking.
Good luck Nurse!

TOS

[santhony44]

I'm a nonsmoker and hate cigarettes, too, but I think we've gone just a tad overboard with this "smoke-free" stuff. And I lecture people on smoking cessation almost every day.

In my experience, the patches work pretty well for smokers up to about a pack a day habit. Over that, not so well. Two packs a day or more and they're going to climb the walls if they can't smoke. (I once worked an epilepsy monitoring unit where the patients were not allowed to go outside to smoke due to their being monitored).

I suspect that, if the patches aren't working and the patient is physically able to get outside the facility, the patient will find a way to go smoke, and you won't be able to stop them. And I agree with cardiac that trying too hard to stop the patient could be a really big mistake.

[nursemike]

The situation is a little unclear at my facility, as well. In some cases, if the patient is ad lib and it isn't otherwise contraindicated, docs have no particular problem with them going out to smoke. Depending on the diagnosis (and, to some extent, the doctor) the doctor may refuse to give permission to smoke. A lot of the patients on my unit have seizure disorders or seizure risk after neurosurgery, or circulatory problems that make smoking contraindicated. In some extreme cases, smoking may be such a risk that if the patient insists, they need to be discharged AMA, since we can't treat them if they won't comply. More often, they're smoking against medical advice, but the level of noncompliance/risk doesn't really justify discharging them. I think we are in the same situation you are--we have AMA discharge forms, but not AMA to smoke (or drink coffee, or get out of bed...whatever.) So about all I know to do is write a nurse's note: Pt AOx3, states "going out to smoke." Advised not to go outside to smoke. Dr. X notified."
Something like that.
Honestly, I think if we just put everybody in restraints upon admission, nobody would feel stigmatized.

[elkpark]

Clearly I'm in the minority on this, but I don't see why it's not handled the same as a client walking out and leaving the hospital for any other reason -- if they refuse to follow medical advice and insist on leaving, that's fine and their choice to make -- but as soon as they're gone, you discharge them AMA, and if/when they return, they don't have a bed any more ...

I've said for years -- if people are well enough to go out and smoke, they're well enough to go home. Discharge 'em; end of problem.

[RN1980]

let'em do what ever he wants to do... just chart that you informed him of all the pros and cons and nasty things that can happen to him outside and he wont be monitored by a nurse while he is smoking for example sudden chest pain, asthma flare-up or even a cva/tia or fall. i but believe me, if a patient leaves your floor and goes outside to suck on a cancer stick and ends up injured or dead, someone will try to hold you accountable. you'll be asked, why did you let him go, why did'nt you go with him, how come you allowed a patient to leave the floor and the hospital without written permisson from the md. the questions and accusations go on and on...just have your ducks in a row, cause crap can and will happen.

[RiverNurse]

Many thanks. In fact, he'd left the floor several times on the previous shift. Because he'd tested positive for THC and there was suspicious activity reported by the previous shift, I took the matter to care conference where the caseworker told me - with a smirk - that I should have *already* called the doctor about the patient's positive drug test and leaving the floor... to go smoke.

I called the doctor and was told (and yelled at) that I should have had the pt sign AMA... The charge nurse also came down on me pretty hard as well.

What *I did* end up doing was charting in the progress notes that the patient had been advised to stay on the floor and that the doctor had been notified. I also noted when the patient came back to the floor. He was discharged later that day.

Now - I have learned a lot these past few months (six months on the floor this past week - woohoo!) about 'letting things go'... But - because of those "chastisements" and the conflict with what I thought was reasonable judgement - I end up feeling confused and 'chaotic'. It's a real dichotomy at times... which is why I write to these forums. Getting input really helps clarify my nursing judgement.

Many thanks,

Shawna

[mercyteapot]

I can't imagine that you'd get written up for this. It doesn't even sound like your facility has an official policy, so how could you have violated it? You asked for advice and you documented the situation. I will personally be outraged if you get any flak for this... (just kidding, but you really should be fine...)