Patient right vs common sense - page 2

:eek: Can someone tell me where the line should be drawn. A while back we had a male patient admitted to Med/ surg with chest pains. His initial cardiac enzymes and EKG were normal. By the time... Read More

  1. by   RNforLongTime
    I too have encountered the same situation with one of our frequent flyer COPD pts. Said pt was just in a week and a half ago. Her doctor was well aware of the fact that this pt went outside to smoke and refused to write an order! I even left him a note asking him to write an order just so the hospital wouldn't be held liable if something happened to this pt while he was off the unit! But he never did and our hospital doesn't have a form for the pt to sign that would not hold the hospital liable if something would happen to her while she was out smoking.

    One of our staff nurses was gonna have her sign AMA if she was taking care of this pt but she never was assigned to care for this pt. And I frankly did not have time to "baby-sit" this pt while she was under my care. I documented each time I cared for her that the pt went outside to smoke against medical orders and that the pt would reply that she was gonna do what she wanted to do regardless of whether she had an order or not.

    It just makes me angry that this doctor would allow us nurses to be held liable. His reply was " I have no control over what she does when I am not here"
    Pt's have a right to smoke if they so choose but if they come to the hospital then they are bound to comply with their treatment plan and smoking was definitely NOT in this pt's treatment plan.
  2. by   tiger
    i don't know about being bound by a treatment plan. a patient can be in the hospital and refuse anything they don't want where i work including meds, refusing to adhere to non smoking even though their o2 sat is 76%, intermittent catheterization, dressing change, shower, you name it... it is a patients right. if you force something on them against their will then i think they have a right to sue. just document everything. if a pt. is in their right mind it is their choice.
  3. by   RNforLongTime
    Ok--they don't have to do ANYTHING they do not want to do! They can refuse whatever they want but then I am not doing them any good either by allowing them to go outside to smoke plus should something happen to them while they are outside smoking--they could sue the hospital and my self and I could lose my hard earned license. If that doctor would just write an order allowing the pt to smoke then there wouldn't be an issue but he refuses to do so each and every time this pt is admitted which is usually about 4 to 6 times a year.
    It is her choice but on the other hand if a person were a druggie--and he wanted some crack or whatever then he should be allowed to have some, right? After all it is their choice.
  4. by   tiger
    smoking is not illegal like crack, etc... if the doctor writes an order for no smoking and you follow it then you are infringing on the pts rights as well as the doctor. all about choice. what if a pt refused you to touch him, clean him up or whatever, would you document but still be worried you could be sued for neglect?????
  5. by   bigjay
    My two cents on this subject.

    Patients who can take themselves outside on their own and smoke will do so, regardless of whether there is an order written or not. A doctor's order isn't going to do much liability wise anyway if something happens. You simply need to document, document, document!

    I agree with not needing to assist or babysit pts who smoke. That's what family members and friends are for. In hospital we are quite able to control a lot of factors but at the same time we can't infringe upon pts rights. As others have said. pts have the right to refuse any care or restrictions placed upon them. Unfortunately as front line health care workers, we get to pick up the pieces afterwards. I try to make sure my patients know the short and long term consequences of their actions and enable them to make their own decisions...
  6. by   Zee_RN
    Someone stated something about patient's responsibility to the treatment plan...

    Every hospital has posted the "Patient's Rights and Responsibilities." (JCAHO requirement) It does state there that the patient's responsibilities include adhering to treatment plan...maybe we should chart that the patient was given a copy of that? Or at least that we reviewed it with them? At least then you have some documentation and JCAHO would probably just LOVE it. Heh.
  7. by   hoolahan
    Alcohol isn't illegal. Tiger, are you saying then, since it is legal, it's OK for the pt to particpate in an activity that is not in the treatment plan? So, if a family member takes an alcoholic pt outside and they drink, then it's OK? Even if they are recovering for an admit for bleeding varices?

    I for one think this whole pt rights thing goes a little too far. If they have copd, or MI, they should not be allowed to go out and smoke...period. If they don't like it, they can sign out. Or better yet, not come to the hospital, or should I say the hotel, in the first place! As the original poster said, there has to be sometime when we draw the line. What is the worst thing that could happen if a pt does not smoke during an admission? They may decide they can breath easier? Gosh, we better prevent that from happening!


    Don't think I am a control freak, from from it. I do home health, and when I go into someone else's home, and see them for copd, I canot ask them to stop smoking, and I know that. In their own home, it certainly is their choice, even if I have to gag my way through the visit and stink like smoke when I leave. I can simply educate them on the consequences. I don't get myself into a lather over pt's not following orders. Hey, they are not hurting me one bit!

    Zee, in home health, our consent forms do have a place that states we reviewed their rights and responsibilites with them, the pt intials each section of the form, and signs the bottom. We have discharged pt's from home care for not following the treament plan. In fact, we have reported pt's to APS for endangering their own lives for this very reason. The bottom line is, nothing usually happens to the pt, but we are covered. There is a section on our admit form, the dreaded OASIS, about "impaired judgement." And, if pt's jeopardize thier health by smoking, drinking, (I am talking heavily here and for appropo diagnosis) or not taking their meds, we check off impaired judgement. So, when they end up back in the hospital, we don't have a "bad outcome."
  8. by   PhantomRN
    I consider the patients right to smoke just that THEIR RIGHT.

    If they have an order to smoke I allow them out with supervision, a CNA or someone needs to go with them. There is usually at least on person on staff who smokes and is more than willing to take a smoke break.

    If they have no order and are insistant I will call the MD and get one. If it is 2 am I will try to hold the patient off til the am until I can talk to the MD. But I always work with the patient and they know if someone is trying to snow 'em or really trying to work with them.

    I had a situation where a patient came in around 3 am I held him off on smoking til morning, put a note on the chart for the doc for a smoking order. The day nurse did not approve of smoking so she took the note off and all day long told the pt he could not smoke. (we have 12 hour shifts.)

    Well anyway when I got there the supervisor was on the floor and security where on their way up. Apparently the day nurse said that she thought he had snuck a butt in the bathroom and had demanded his smokes. Well as you might imagine it went down hill from there.

    So the super sees me and says "you have a good repoir with him go get his cigs from him and tell him I will hold them until he is d/ed."

    Instead I went to the phone paged the MD and asked if he seen the note...no he says......and he goes on to say that no one had mentioned a smoking order to him and that everytime this patient comes in he needs one, and he didnt order it because he was being hopeful that he wouldnt want it this time.
    Well he gave me the order.

    I could have wrung the day nurses neck....I consider that patient abuse.
  9. by   tiger
    i think it is a bit of a control issue. if the family brings in cigarretes , and the pt goes out on his own to smoke, and you have documented properly, then why do you care??
  10. by   RNforLongTime
    It has nothing to do with control but about being liable or accountable.

    Yes, a pt will do what they want to do regardless of whether they have an order or not. It is my job to educate them on the benefits of quitting smoking as well as the risks they are posing to their health. I did not prevent this pt from going outside to smoke but am upset with her attending MD for being complacent and basically shrugging the situation off

    So lets say the pt passes out while she is outside smoking. She doesn't have an order to allow her to do this. I as her RN for the night can be held responsible for her injuries. That is my whole point. I documented each night that she was informed that she did NOT have an order allowing her to go out to smoke and that she continued to do so, against medical advice. Like Hoolihan said, it's like we are a Hotel Solumedrol and not a hospital!
  11. by   hoolahan
    Again, I have to agree with kaknurse. It is a hospital. People come there, I presume, to get well. Smoking after a new MI does NOT make you well, it does nothing to improve your condition, in fact, it may make it worse!

    I do not wish to control pt's, but feel free to think that if it works for you. If they want to kill themselves, I just wish they would do it on their own time, not mine. It's no skin off my nose if they kill more of their cardiac tissue! I've had pt's who were in renal failure, CHF, etc, who would not stick to their fluid limit. Did I "control" them when they went over the limit? NO, I don't even try. I just inform them of what the limit is, how many 8 oz glasses of water or whatever that translates into, and show them how much they've already have and what may happen if they go over. Frankly, if they don't want to follow their fluid limit, I don't care, as I said, they are only hurting themselves, not me. I'll even fill up their water pitcher for them and let them knock themselves out! At least you can treat that with a hit of lasix, usually. Now, what will the pt have to go through when they have chest pain after they smoke? It's a bit more involved. First thing that is done is put the pt on oxygen....uh-oh, poor baby, now they can't smoke on oxygen. Not to mention, possibly needing NTG tab/drip, transfer back to CCU, EKG, enzymes....is it really worth it?? I guess for some it is. I realize it is an addiction, but are we supposed to perpetuate an addiction???? Sympathize, empathize, yes, but encourage it....I don't think so.
    Last edit by hoolahan on Aug 22, '01

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Patient right vs common sense