ethical question

kanzi monkey · Apr 7, 2009

I flushed her IV with saline (since it was a new IV). She thought I was giving her some sort of medicine. I did not confirm or deny it. I just said, "it's time to relax now".

How do you know she thought you were giving her a med? Did she ask you? How did you respond...or did you just say that it was time to relax?

At 0530 she woke up to void and asked if she could have "some of that same great medicine". Again, I didn't confirm or deny it and our saline flushes are due at 0600, 1400, and 2200. Since it was 0530, without a word, I flushed her IV again.

So, when she said this, you didn't say anything (related to her statement or otherwise) and then your next action was to flush her IV?

I have moments where I take opportunities to be "vague" because I personally feel that a patient will benefit with less information at that moment (ie, what it means that I'm drawing a B set of cardiac enzymes and the A set was slightly elevated. They don't need to know the details, I'm sure they will still know to tell me if they are having chest pain--but just in case I will always ask as part of each assessment :) ). Yes this is an example of paternalism. But it's a judgement call. If they ask a probing question ("Is this going to tell you whether or not I'm having a heart attack?") I will answer them as best as I can or get an MD to their bedside--but if they seem relatively unconcerned (because they are unaware) when I draw their labs, if they ask I'll say "just checking out some of your chemistries"--I'll say that even if they don't ask.

But if a patient asks a direct question, or implies a question, or states an assumption about any treatment (or medication!) you are giving them, really your only option is to disclose what you are doing or correct them if they are misinformed. You don't have to say "this is normal saline, and thus it definitely WON'T help you sleep"--you can laugh gently and say you are just flushing their IV, then change the subject and talk about relaxation techniques, put some lotion on her back, ask her if she needs more pillows, etc.

Besides the non-disclosure element of your story (tsk tsk), the one other question that comes to my mind is that maybe investigating her nausea and anxiety (and the fact that she says she usually takes ambien) is important. I would ask her about how she usually sleeps at night, what she thinks is making her nauseas, and if she takes benzos on a regular basis (maybe she takes ativan in addition to ambien) which was accidentally left off her med list. In my experience, this happens sort of a lot, and patient's tend to be unaware of symptoms of benzo withdrawal. Maybe they thought they wouldn't need them in the hospital, maybe they've been taking them regularly without a prescription. Whatever the reason, you want to know that something like this isn't what's going on.

I definitely don't think you're the worst nurse, or even a bad nurse. You sound like a good nurse, in fact :) And I admire that you are taking this situation to heart and asking for advice--it's hard to put yourself on the line like that. You ask us because you care about your patients.

-Kan

MO3BB · Apr 7, 2009

I don't remember her exact words but she was begging me to call the doctor to give her something for her "craziness". All the night shift nurses the night before and day shift had repeatedly called the doctor to ask for ativan or xanax or anything else that might help her become less restless so I knew that a phone call on my part (especially to the particular doctor on call that night) was going to be futile. I reassured her that it was most certainly related to her lack of sleep and that she needed to relax and try to sleep. She kept saying that she couldn't and I told her I'd try to help her sleep. It was at that point that I got her back into bed after starting her IV. (btw, the ambien was something that had been originally ordered on admission, not something she took normally at home, and it had been dc'd at some point during her stay--not completely sure why as I never got it in report and couldn't find anything in the notes about it). As I was flushing her IV she thanked me for me trying to help her sleep (which is how I figured she must have thought it was a med). I stayed and talked quietly with her and fluffed her pillows, brought her a fan (she said she was hot), fixed her blankets, gave her ice water, etc.--that was my idea of "helping her sleep" but her idea was a medication I gathered. But like I said, I didn't confirm or deny it. Then in the morning when she asked for "that great medicine" again I guess I shouldn't say "without a word I flushed her IV" because I didn't just walk in, flush it, and leave. I meant without a word about it being or not being a medication. I took the flush in, scanned her band, scanned the flush, flushed it, asked her if she slept well earlier to which she said, "Oh yes! Thank you so much!" I asked her if the fan helped, if she was too hot or too cold right now, etc. I guess I worked it in my mind that her asking for "that great medicine" again meant to me that she was asking for the flush again even though in her mind it wasn't just a flush.

In the end, I am seeing your individual points which is why I asked the question in the first place. I wanted a different perspective other than my own. I always try to treat patients like I would treat a family member. If that had been my mom and she was suddenly better after a mysterious injection I would have asked what it was (had I been asked I would have been completely honest). If the nurse said, "nothing actually, just saline" then I would be happy to know that we needed to look in a different direction for what the problem really was. Not a GI problem but more of a psychological problem. She had been making comments all along about being lonely and alone. Her family would visit her, she would be just fine, then they would leave and she would say, "I'm just an old discarded shoe, lying in the corner...." Which was another clue to me that her nausea was more than just nausea. I began to feel like it was a reason for her to be on her call light. She needed attention. Which is why I stayed and talked for a while with her and tried to make her as comfortable as possible without medication because I didn't think it was what she really needed even if she thought otherwise.

GrumpyRN63, ADN, RN · Apr 7, 2009

I think anyone who has been awake for 2 days, anxious and restless would eventually pass out, but did the pt benefit? Why did she assume she was getting medication if it was neither 'confirmed or denied'? Did she not ask what you were giving her. Does one just push something through someone's IV and not explain to them what you are giving and why ? It is also apparent she was confused as she pulled her IV out , didn't remember and was having diff expressing herself. Was this a change in mental status that should have been evaluated. N/V how long, fluid and electrolyte status? The previous nurse asked for an order for anti-anxiety med, did she not get one? What's the problem with calling back the doc for an order? When she woke up and asked for that 'great medicine' again in the am, it would have been a really good opportunity to be honest and tell her she only received a flush.

The pt assumes she has received something that helped her. How does the facade continue? What does the next nurse say or do when the pt asks for that 'great medicine' again ? What happens to the level of trust ( to you and now the nurses in general) when the next nurse tells her she didn't receive any med?? It's really not the nurse to decide to use a placebo. A placebo would require a pt's consent to a double-blind study. We really shouldn't be conducting these experiments on our own. The entire thing is just wrong.

GrumpyRN63, ADN, RN · Apr 7, 2009

First of all I'm a student, so I know alot of nurses on here is going to beat me over the head for even commenting but you asked for our input so here is mine:
Yes, you did something very wrong here. I'm not saying you are the worst nurse in the world, you are human and everyone makes mistakes. Number one you made the pt. think you were giving a med. That in its self is wrong. What if she had some kind of some insidous s/s she can blame that on the "medicine" you gave her even though you didn't give anything. Second, if she is requesting this medicine from the next nurse, and the nurse check the MAR and don't see your initials signed off, guess who's in trouble ??? The appropiate response would of been " No, this is just NS that I'm flushing your IV with, however since you really can't sleep maybe I can request a med for the doc to prescribe. " Now if five minutes you come back to check on her and she's asleep, obviously you aren't going to wake her up and give her a sleep aid. The fact that you neither confirmed or denied giving a med is also not appropiate. Thats the same as lying. I know I'm a only a student but right is right and wrong is wrong and I feel that ethically its wrong. Just my two cents, I pray that this whole thing will just be a learning experience and nothing more and nothing less.

Maybe "only a student '' today, but An excellent nurse tomorrow :nurse:

Virgo_RN, BSN, RN · Apr 7, 2009

The first time you flushed her IV, you should have explained to her what you were going to do prior to doing it. Having overlooked this, her misperception that you gave her medication that helped her sleep is understandable. The second flush as you described it shows intent to deceive, which is unethical, IMO.

StrwbryblndRN · Apr 7, 2009

I agree with the previous post. Knowing a pt is misunderstanding and not correcting it is unethical.

I would hate to have any other nurses for the pt explain otherwise and make you look bad. Not only to the pt but to

others around you.

I like to believe I always tell the truth and never mislead. However I do not offer info that would open a can of worms either.

Zana2 · Apr 7, 2009

Medical ethics is a very grey area. I have a code of conduct that I must obey, and the law. However, in my research I found that there is a clear line between beneficence and malevolence. Your 'silence' was not, in my opinion, malevolent, the woman slept, had a much needed rest. Yes, i think it's wrong not to tell her that is's just saline, doesn't do anything to alleviate her symptoms. But your action was driven not by the desire to lie to the patient and have a good laugh afterwards, it was not instigated by you.

Putting myself in your shoes, I think I would have raised the issue with the nurse in charge straight after the first 'incident' and sought some sort of counsel. It's an ackward spot to be in. Keep your emotions in check and be ready to justify your action in a calm, rational manner. X

nicu4me · Apr 7, 2009

To the nursing student post re not waking someone up for a pain or sleeping med = you need to talk to your instructor on that. You should be waking them up. Sleeping does not = no pain. It is a diversional activity ie; talking, walking, watching t.v., laughing. Give pain meds when they are due and wake the patient up even if they fell asleep in between the time that they did and when you get it ready to give. Sleeping aid - patient sleeping when you want to give it --- same thing. It's 10:15 pm pt sleeping, just asked for sleep aid you check the patient and now she's ringing and it's 1:00 am and she can't sleep. Well, you missed the magic midnoc or 1:00 am rule in most hospitals re: times you can give sleep meds. The OP pt had psych issues going on, its obvious. She didn't need to call for a stat order of ativan. Can you imagine her going in and waking her up and giving her a med that she didn't need now that she was already comforted and resting calmly. To "cover" one's behind like that is wrong. And to another post, LIS for n/v isn't what she needed, and to ask for an order for that was also inappropriate. She wasn't vomiting. Had this pt had n/v and nothing was being done about it by the OP and she just restarted the IV then that was wrong. HOwever the OP says she wasn't n/v anymore. She just needed the holistic TLC that she got. I am with the OP. She documented and reported off what happened = no cover up. My response as the am nurse would be, I heard you slept well but actually I think the noc nurse has a great way about her, she's very comforting and easy to talk to. Are you having n/v, anxiety now? If so, I will call for an order and see what we can do about it, however last noc all she did was restart your IV and spend a few minutes with you to make you more comfortable. What would you like me to do? Do you want me to sit with you for a few minutes to figure it out. That's all it takes, it doesn't reflect badly on the noc nurse or nurses in general. Sometimes you need another personality to work with to feel better. Good example, we had a sitter who was from Poland that sat with the confused patients. I could lay there and let her take care of me all day and I know I wouldn't need a pain med in the world. Think of L/D nurses, guided imagery, etc. Are they placebos? Just my 2 cents, I just don't think the OP needed the beatings on this but would suggest she tell NM. And the other workers, it may be a cultural thing or personal thing between them and OP. Gossiping is the worst!

kanzi monkey · Apr 8, 2009

The OP pt had psych issues going on, its obvious. She didn't need to call for a stat order of ativan.

A stat order of Ativan is pretty much for a seizure, and I can't think of another reason. But an order for ativan for someone who may be withdrawing is not only appropriate, it's critical. I don't think anything about the physical or psychological state of this pt is 'obvious' from the way the story was told--need vitals and hx. Many many many pt's present like this, and there are many different reasons why.

And the other workers, it may be a cultural thing or personal thing between them and OP. Gossiping is the worst!

Absolutely. And for the most part, I agree with everything you said in your post. The relationship with the patient is about honesty and appropriate disclosure, and I think your suggestions for the daytime nurse are great. You have a way of "keeping it real" as they say :) This whole idea that a group of nurses may team up on another nurse, or accuse her of inappropriate care/poor ethical judgement is just wretched. We all (for the most part) have good intentions, but sometimes in retrospect we feel we might have handled something differently. And then we learn and try another way the next time. I find that nurses can be extremely unforgiving of their colleagues--making quick judgments on their character before just recognizing that people do things differently, and their isn't a protocol for every situation.

-Kan

cherex74369 · Apr 8, 2009

Well, try this on for size...

I have had pt.'s ask for their pain meds, claiming rated 10/10 and hurts like h^&%. I go get the med and return to find them snoring like drunken fools!!!! Im' not one to wake slleping dogs or little babies, so I hold the med (in case it's needed later when they wakd again) and they go ALL NIGHT w/o requesting anything further. Then I overhear them tell docs in the morning that "That pain medicine last night was really GREAT stuff, I slept all night with it!!"