Ethical/moral issue - page 3
by dee78 | 6,938 Views | 40 Comments
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... Read More
- 0Nov 30, '12 by RNewbieQuote 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.
- 0Nov 30, '12 by jadelpn GuideWhen 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.
- 0Nov 30, '12 by jadelpn GuideOh, 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.
- 0I 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.
- 1Nov 30, '12 by Esme12, BSN, RN Senior ModeratorGood Lord! What a cluster! Unbelievable.......here is what makes me angry. You are a new nurse, something I think the patient was perfectly aware of....you had your hands full and it sounds like you have a difficult population. Where was your charge nurse and supervisor before this escalated to this.....and if this patient is known for this behavior a plan should be available to the staff to NOT deal with this a 1030 at night.
If the write up was for the IV....ok.....or maybe the write up was to cover her behind because she should have been involved early to prevent this escalation. Going forward...this patient is now going to pull this EVERY time. Patients like these present challenges. I have worked at facilities that let the patient know they are discharged....period. They are escorted to the door goodnight. I have worked at facilities that are afraid of a "lawsuit" and will mollycoddle these patients endlessly I have worked at places that find respite beds for them, a homeless shelter, or will place them in assisted living or PC to police custody.
These patients are extremely difficult each one present challenges. They know the system and they know how to use it. As a supervisor.....I would have postponed the discharge until days and made it clear to the patient that this will not be tolerated and from now on there will be a plan b and they will be discharged on days to a place of their choosing....or perhaps this is an indicating they require a higher level of care like a SNF. Change his meds to PO (they should have been already) and remove all IV access. But unfortunately......sometimes you just get stuck. Involve your charge early on and call the supervisor ASAP.....pass the buck.
You had a difficult night..you did the best you could. Many patients will say the pain med doesn't work if they don't get the med they want....falling asleep in not an indicator that the pain med is working....it's an indicator that they want a specific pain med. I think you did a good job.
Let us know how it goes and if the patient finally goes....Good Luck!
- 17Update: I got an email back from my assistant nurse manager, she assured me that there will be no write up. It was a messy situation, she said I handled it to the best of my ability. So lesson learned, no black cloud over my young career.
- 1Nov 30, '12 by cienurseI am curious about a patient being discharged to a home where he has no key of his own and is dependent on someone else to open the door for him........or NOT? That can't be a good living situation in the first place and its up to the social services department to make sure that it is a SAFE discharge or to notify protective services when a patient insists on going to an unsafe place or leaves against medical advice.
- 1I don't believe they knew about this situation. We talked quite a bit the first night I had him and he lead me to believe he LIVED there with his sister. It wasn't until the moment of discharge that he said he didn't have a key.Last edit by dee78 on Nov 30, '12 : Reason: Redundant