Ethical/moral issue - page 2
Background: Patient is inpatient in an acute care facility due to dialysis non-compliance. Patient had to have security called during admission due to behavior. Patient is verbally abusive to... Read More
Nov 29, '12We might work in the same place. Laugh out loud. Frankly, discharging the patient is the right choice and I wouldn't give meds until they are due. If he has been getting them q 6, then I would give them until 5 hours and 45 minutes at the earliest if the Pyxis even allows me to pull them.
Nov 29, '12Quote from doeRAYmeeYeah I was wondering this too. What decision was made?Why were you written up?
Nov 29, '12Quote from dee78This discharge plan was doomed to failure from the start, and I do wish someone would have said, "hey doc -- by the time Mr. X gets his PermaCath and completes dialysis it's going to be too unreasonably late in the evening to discharge him." And come up with Plan B.Background:
Patient is inpatient in an acute care facility due to dialysis non-compliance. Patient had to have security called during admission due to behavior. Patient is verbally abusive to staff and threatens lawsuits any time he doesn't get his way. Patient is to be discharged but claims he will file a lawsuit if discharged without a perm cath for dialysis, he says it hurts when they dialysis through a newly matured fistula. Doctors schedule the placement for the following evening, with orders for him to dialyze and be discharged.
Orders are carried out, patient discharge is completed within 15 minutes of returning to floor. Patient gets ready to go, taxi is called. Patient calls out that he needs his nurse, nurse responds and patient states that he can't leave because no one is at the house he stays at and he won't just sit out in the cold all night.
This is actually quite common in our facility, patients are discharged and we even pay for their cab home but then they refuse to leave. Typically, the patient is put in the cab and sent on their way, even if it is to a homeless shelter. Sometimes security has to be called to escort the patient to the cab.
There are a few things that make this a more ethical dilemma. The discharge is at 2200 on a very cold night. The patient is blind. Patient has been walking up and down the hall on his own and going outside to smoke. Patient is receiving IV pain medication and gets very upset when it is not given when he asks for it, even after being told that he can have it at 00:00.
Do you ask the doctor to allow the patient to stay another night even though there is no medical necessity? If so, do you put stipulations such as no IV pain medication?
Do you call the cab and send him on his way to wherever he wants to go?
Do you call security to escort him to the cab?
I have to say I really can't imagine any of the renal group at my hospital agreeing to abandon a newly matured but perfectly functional fistula so quickly. The central-line associated infection risk of a PermaCath or VasCath is an absolute last resort.
So I think there are a number of things about this scenario that should be examined from a purely practical, logical stance, before we get to the ethical/moral quandary.
But to play along ...
1. Patients whose planned discharge is within 24 hours from now who are not going to some kind of continued care (skilled nursing, rehab, hospice, etc) should be transitioned from IV pain meds to oral meds. It has nothing to do with the manipulative behavior of this particular patient.
2. Yes, I have had to call security to escort discharged patients out of the building.
3. No, I would not put a blind patient in a cab to go home to an empty house at 2200.Last edit by Altra on Nov 29, '12
Nov 29, '12It sounds to me like an excuse on his part, really. He knew he was to be discharged and suddenly as its happening he decides to mention he has no one to let him in? He's an adult and should be held accountable for his own life. Obviously he is functional if he can go out to smoke independently.
Unfortunately the culture is give me what I want or I'll sue, and the nurses have to bend over backward to help people who refuse to help themselves.
Nov 29, '12It is hard to type it all without too many details.
I honestly do not know what I was written up about, house supervisor just said that she was writing the 4 of us up (unit clerk, case manager, charge nurse, and myself). The only part I played in the situation was that the patient was escorted out before I dc'd his IV. I was waiting until taxi called to say they were almost there and never got that call. I was overwhelmed, I had the discharge (my first on my own) and an admission, as well as 3 other patients. I thought that maybe the charge nurse had taken care of it, I did tell her that it wasn't dc'd. I can accept that I made that mistake, I am not making excuses but I was almost in tears. I had just finished the admission assessment when d/c was brought back to the floor and new admit needed pain medication since he hadn't had any since before he went to the ED about mid-morning. Then after giving 2mg of morphine, patient accuses me of giving a placebo because he didn't get any relief and was still wide awake and hurting. All the while patient 3 is also uncontrolled pain, never less than 8 even after Dilaudid/Percocet coverage, crying out to "Dear Lord Jesus" at the top of her lungs. The ADHD tech was calling constantly about doing a bath/dressing change at the same time on pt 3 because the pt was very uncooperative and fluffy.
I am guessing that they agreed to the Permacath either due to the threat of lawsuit or that he would refuse HD and end up hospitalized again in a week, that is what got him admitted.
I agree that he should have been transitioned from IV to PO, I am not sure why he was not. As a new nurse, I am still learning to question orders and suggest changes.
I do not know why the day nurse did not question the timing of the discharge, I did think it was late. I did not agree with the discharge (knowing he had nowhere to go), I told the charge that I had no problem taking care of him the rest of the night. We had a good rapport the night before and I was sure I could get him calmed down. Ultimately, when I was with my other patient, the case manager (from home) said to put him in a taxi to the homeless shelter.
I am sure that looking back there are many things that could/should have been done differently. I have been a nurse for 4 months, I am learning as I go. Some lessons are harder than others. I am analyzing the situation, what went wrong, what could I have done differently, how can I prevent it in the future. You guys have helped me. Thanks.
Nov 29, '12So how did ya'll get the IV out, did he come back or did you go to him?? I ask because when I was a new nurse I DC'd a pt with the IV in place also. Thankfully the daughter brought him back to the ED entrance, I removed it, covered it and the pt went on home. Yes, I was written up for that.
You could have been written up for being part of the "unjust DC or the IV"..
Nov 30, '12You could've been written up because the administration wants a paper trail to cover their butts that they "took appropriate action" incase this guy decides to sue. It's total BS in my opinion.
I agree with the poster who said you shouldn't have to deal with a discharge problem anymore than a social worker should have to deal with placing a catheter or giving medication. Unfortunately, we're human so we always end up getting involved in those cases. I always worry when elderly people tell me stories about their pets at home or whatever.
When I was working as an intern there was a guy who I don't remember what his admitting dx was, but I remember it was the result of being overweight, having a BP through the roof, and basically all poor lifestyle related. He was IRATE that he was being discharged because he said he didn't have the money to fill his prescriptions. So, he was like, "I'm just going to get out of here, go home without my medicine, and end up right back here so it doesn't make sense for them to send me home."
That actually makes sense....except it was lunch time while he was telling me this and he was eating a cheeseburger with extra cheese and he was actually stacking french fries onto his burger like it was lettuce and his remaining fries were covered with mayonaisse! He's literally sitting in a chair with a blanket covering his bottom half because his pants don't fit well and licking his fingers while telling his story. I couldn't help but thinking, "Gee, if you're SO concerned about your BP and ending up back here, why don't you put that McFryBurger down!" There are so many lose-lose situations like that...it's frustrating.
Nov 30, '12Quote from dee78Did you sign the write up slip yet? What did it say was the reason for the write up? This was a tough situation. I probably would have discussed the situation with the supervisor to begin with to see what they suggest be done with this pt. I have accidentally left an IV in before as well. We all make mistakes. Most pts who are not drug users will have the sense to take them out themselves. I think I would have been more inclined to let the doc and supervisor know that I would suggest holding off on D/C since the pt was the type to threaten to sue. Nursing has it grey areas when things are not always black or white. I don't think it deserved a write up, maybe have a talk with all involved and give a written warning. Btw, what was the clerk written up for? Discharging the pt from the system?We were called down to the loading area. I would accept the write up over the IV.
Nov 30, '12It was just a few days ago so I have not seen the write up. The clerk was the one making most of the phone calls.
Nov 30, '12When it became apparent that this patient was involved in some emotional issues that were/were not within his control, then I would (and we all know discharge planning starts on admission) really have doubts as to this patient's ability to make choices that are sound. To advocate for this patient I would ask for a cognitive evaluation. A psych consult. Does this patient need a guardian? Does this patient need to go to skilled care? Get case management and social work on this from the first day. There needs to be a discharge plan that works. 10pm at night is not an ideal time for a patient with multiple comorbitities to go home. In a pp OP mentions that they were all "written up". Why? On day of discharge, did social work not see this patient, go over discharge plan, and do something that the patient could be discharged during daylight hours?
When all is said and done, the only thing we can do as nurses is advocate, document, and make sure our own discharge teaching is in order. Team efforts include that of the social worker. If cognitively and psychologically this patient was not able to care for themselves, then you need to create an alternate care/discharge plan. Even if it is a transfer to a psych facility on a section, due to a danger to self. If this patient lives in a home with family, then it is within his best interest for the social worker to call family and say "so and so is being discharged today" and then take it from there if they say "no thank you". Again, an alternate discharge plan needs to be put into play. But it does sound like this patient would do much better in a skilled care facility.
Nov 30, '12Oh, I am seeing now that the write up was over the IV. Well, we all make mistakes, and the IV was taken out before the patient left.
So the patient was discharged to the homeless shelter?
If this patient dawns your doorstep again, I would be 100% sure of my documentation, and speak to the MD and social work regarding some alternate plans of care and discharge plans.
Nov 30, '12I do know that discharge does begin at admission but with so many of our patients it simply isn't that simple. Case management did their job, this discharge plan was approved by everyone the night before. I suppose in an ideal world there would be a plan B on all patient discharges.
I will hopefully know more about the write up this evening.