Consents when under the influence

  1. I had a pt today with a really gnarly compound dislocation/fx that I knew from the get-go would be sent to the OR. By the time I got the wording of the consent from the surgeon the pt had been medicated with two different narcotics. I've never been comfortable getting a consent from a medicated pt but was always admonished that if the pt was still able to understand the consent and the reasons for it, I could have them sign. To protect my own butt I've always had a relative co-sign, if at all possible. The ER doc saw me doing that today and made fun of me.

    Another problem with consents. We transfer all of our pts that need a psych eval because we don't have mental health. I never get a psych pt on a hold to sign a consent because it's being done against their will. I figure if they're on a hold because they're a danger to themselves, they are not capable of consenting. Other nurses tell me I'm being silly, that they can still consent.

    What do you guys do? Should I stick to my guns and continue my practice, or should I give in?
    Last edit by TazziRN on Nov 21, '06 : Reason: Incomplete
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  2. 20 Comments

  3. by   augigi
    Not sure about psych patients, but agree about narcotics. Don't worry about the doc - better he laughs now than when you're in court.
  4. by   ERNP
    If they are able to understand the procedure and have had an opportunity to have all their questions answered by the surgeon (that is the part that I get hung up on) then they can sign for themselves. That being said it is never a bad idea to have an unmedicated family member sign when available.

    IMHO, involuntary psychs don't have to sign consent for transfer. Are you gonna not send them because they say no? So, it really is just potentially another battle to take up valuable time. It doesn't change the outcome.
  5. by   IMustBeCrazy
    Absolutely still ask involuntary psych pts to sign consent. Most will refuse, and that's ok. But chart it as 'refused', especially on admission paperwork.
  6. by   ceecel.dee
    The impaired cannot give consent legally, whether we have impaired them for their comfort or they are impaired intrinsically.
    That surgeon is a boob and attempting to intimidate you through humiliation. You may well have the last laugh (about him) one day. He should be thanking you for your diligence.
  7. by   Kyrshamarks
    By law you are not obtaining consent when signing the patient signs the consent form. The DOCTOR has to be the one that obtains the consent, your signature merely states that you witnessed the patient sign the consent. UNDER NO CIRCUMSTANCES should you be the one obtaining consent. The courts would go after you if something bad happened during the procedure.
  8. by   ceecel.dee
    Well, it is the doc's job to go over options, risks, benefits, etc with the patient. The collective "they" do not do this for the most part (if they did take the time to speak about it, did the patient understand it?), it does fall to us to be sure the patient understands what will be done unto him. Informed consent means that the patient understands what he is getting himself into and makes the choice to allow it after hearing the good, the bad and the ugly about it. Yes, it's the doctors job, but like alot of other things that are supposed to be done by someone else, the nurse picks up the slack, for the patient's sake.
  9. by   tvccrn
    I have been told by our legal expert here at our facility that you can't get informed consent from a patient that has had narcotics within the last 8 hours. If they can't sign a legal contract they can't give consent.

    I know that having had morphine as a patient that I wouldn't not have been able to comprehend or retain anything I was told while under the influence.

    To me this is just a lawsuit waiting to happen and I wouldn't want to have been the one to witness this event.

    tvccrn
  10. by   RunnerRN
    I will still consent psych pts because a lot of them, even the ones w a hold, are voluntary. I figure giving them the benefits and risks can't hurt....and if we have a hold, and they refuse to sign, then they go anyway. I just think allowing them to wield some power helps everyone.
  11. by   nuangel1
    Quote from Kyrshamarks
    By law you are not obtaining consent when signing the patient signs the consent form. The DOCTOR has to be the one that obtains the consent, your signature merely states that you witnessed the patient sign the consent. UNDER NO CIRCUMSTANCES should you be the one obtaining consent. The courts would go after you if something bad happened during the procedure.
    you are absolutely correct .we as a nurse can witness the pt signing the document to consent for procedure.after md expalins the procedure .but under no circumstances are we as nurses qualified to obtain the actual consent of the pt for the procedure.the only consents i as a nurse obtain are for ct scan ie asking pts consent to have contrst and the ct scan.as far as psych pts if they are on a psych hold it depends on whether its a voluntary or involuntary.if its a voluntary hold the pt signs consent for transfer to a psych facility if its a involuntary hold we do not obtain pts consent.involuntary means pt has been found to be risk to self and or other .
  12. by   SOREFEETEMPTYSTOMACH
    tHIS IS A LOADED TOPIC BUT VERY COMMON IN E.R. WHICH IS WHERE I EARNED MY MILLIONS.
    The doc. must explain the procedure or it isn't informed consent. When the patient is impaired 2 witnesses is a good idea and it is on the surgeon's shoulders. The worst thing for you as a nurse is to be perceived as withholding care due to the patient's impaired condition. :smilecoffeeIlovecof
  13. by   TazziRN
    Quote from SOREFEETEMPTYSTOMACH
    tHIS IS A LOADED TOPIC BUT VERY COMMON IN E.R. WHICH IS WHERE I EARNED MY MILLIONS.
    The doc. must explain the procedure or it isn't informed consent. When the patient is impaired 2 witnesses is a good idea and it is on the surgeon's shoulders. The worst thing for you as a nurse is to be perceived as withholding care due to the patient's impaired condition. :smilecoffeeIlovecof

    Clarification: the doc DID explain the procedure and got the pt's verbal consent. All I did was witness his signature after he was able to verbalize to me his understanding of what the surgeon said. When I say I obtained the consent, I did......I handed him the consent form and obtained his signature, along with that of his wife's. Although legally the doc is supposed to get the consent, I have never ever ever seen a doc do this, have you? I would never obtain consent if the pt wasn't able to prove to me he understood.

    My question was about the legalities of obtaining a consent from an impaired pt, be it due to narcotics or psych, even if the pt can verbalize understanding. The docs say I'm too anal about it. Am I or not?
  14. by   IMustBeCrazy
    I never understand why the medical profession handles psych pts as if they are the scourge of the earth. According to the psych pts I have worked with, one of the things that upsets them the most when they come to the hospital is how they are treated less than human. Granted, if they are delusional, homicidal and paranoid, you are probably not going to get far with them nor would it be safe to give them a pen.

    But even on an involuntary hold, the MD *should* explain that they are dangerous to self or others and are being placed on hold, at which time they can be asked to sign into the psychiatric unit for their own protection. They may well refuse, but ED has done its duty to ask for the signature.

    I have had to de-escalate many psych pts on the unit after they were treated without dignity in the ED.

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