medical abuse?

Nurses Safety

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I hope this is in the right section......

I'm a nursing student, and I had an uncomfortable situation come up with my clinical instructor today. I'm wondering if we were abusive towards the patient. Let me explain. An eldery female patient with dementia had an order for an in and out foley. We explained several times to her what we needed to do, and why, but she kept on forgetting. Despite us telling her over and over why we needed to do a foley and what it was for, she kept on saying "no" "don't" and "that hurts". Despite her saying "no", "don't" and "that hurts", my clinical instructor instructed my classmate to continue with the foley. The patient started to cry. I felt really uncomfortable with my instructor having my classmate continue to do the procedure. It felt like rape or abuse. What do you all think about this?

Specializes in Pedi.
I think we're confusing situations where signed consent is needed vs where only verbal consent is needed. Consent is actually required for straight cathing even though signed consent is usually not required. Consent is required for each time we draw labs and even give medications as well, it just doesn't have to be in writing. The only exceptions are where the patient is incompetent to make medical decisions or where a Physician has declared medical necessity in place of consent.

I'm a pediatric nurse. If I have a child whose parents are not present and the child hasn't voided x 8 hrs post-op, I don't call the parents in the middle of the night and say "we need to straight cath Johnny." Have never once done that. Little Johnny might cry and say "don't do that" when we go in to cath him but we do it because it's necessary. I view the situation the OP describes as the same. The patient was demented, she likely lacks the capacity to consent to treatment.

Specializes in Critical Care.
I'm a pediatric nurse. If I have a child whose parents are not present and the child hasn't voided x 8 hrs post-op, I don't call the parents in the middle of the night and say "we need to straight cath Johnny." Have never once done that. Little Johnny might cry and say "don't do that" when we go in to cath him but we do it because it's necessary. I view the situation the OP describes as the same. The patient was demented, she likely lacks the capacity to consent to treatment.

Minors are different, that's were a general "consent to treat" is obtained, no such thing exists in adults who are not cognitively impaired, such as yourself when you went to the ER which is what I was referring to.

Specializes in ACNP-BC, Adult Critical Care, Cardiology.

A good rule to follow when we're faced with dilemma's like the OP's situation is to go through each Ethical Principle in Medicine and Healthcare and see if the situation passes the test for each principle:

1. Autonomy - patients have a right to choose and refuse treatments

2. Beneficence - we should act in the best interest of the patient as providers

3. Non-maleficence - we should do no harm

4. Justice - scarce resources should be distributed fairly

5. Respect - patients are to be treated with dignity

6. Truthfulness and honesty - especially in presenting treatment options, seeking consent.

Number 1 is problematic in this case granted that all the others above were observed (i.e., the procedure was done with an intended purpose to treat, carried out safely, and done in a dignified manner preserving patient privacy).

However, if you analyze the principle of autonomy, it only applies to patients competent enough to act autonomously: (1) ability to make or recognize their choices, (2) understand the risks and benefits of the choices, (3) and maintain this ability over time (i.e., no waxing and waning mental status). In this case, I would err on covering all bases and would prefer to let a responsible family member know of the decision to do the straight catheterization and obtain a verbal permission as a proxy to preserve the principle of autonomy.

Another consideration: I had a delightful ethnic old lady who told me wonderful stories about her Papa teaching her to drive around the 1910 period, and how her Mama and Papa were wonderful and loved her, sent her to a good school run by the Sisters and the Fathers, and gave her everything. She married late in life to an older man, never had children, and asked our agency to see that she was kept at home until she died. I was charged with overseeing the expenditures and the caregivers, who were, fortunately, very good.

Alas, she got to the point where she needed to go to a SNF for her own safety and didn't realize she wasn't at home, so I approved the transfer and set up the billing. Her primary caregiver and I met there one day to visit her. She needed her diaper changed, so we did it. As we were cleaning her, we noticed she was pretty red and sore looking, so we were trying to be gentle.

And all the while, this sweet demented woman was fighting us and crying out, "No, Father, no, please don't, Father, no, no, Father, stop ..."

The caregiver and I looked at each other over the bed and she said, "Whoever he was, may he rot in hell for all eternity." It still makes me tear up to think of her.

Think about that, too, when you have to do an intimate procedure on a "demented" woman who fights you.

Another consideration: I had a delightful ethnic old lady who told me wonderful stories about her Papa teaching her to drive around the 1910 period, and how her Mama and Papa were wonderful and loved her, sent her to a good school run by the Sisters and the Fathers, and gave her everything. She married late in life to an older man, never had children, and asked our agency to see that she was kept at home until she died. I was charged with overseeing the expenditures and the caregivers, who were, fortunately, very good.

Alas, she got to the point where she needed to go to a SNF for her own safety and didn't realize she wasn't at home, so I approved the transfer and set up the billing. Her primary caregiver and I met there one day to visit her. She needed her diaper changed, so we did it. As we were cleaning her, we noticed she was pretty red and sore looking, so we were trying to be gentle.

And all the while, this sweet demented woman was fighting us and crying out, "No, Father, no, please don't, Father, no, no, Father, stop ..."

The caregiver and I looked at each other over the bed and she said, "Whoever he was, may he rot in hell for all eternity." It still makes me tear up to think of her.

Think about that, too, when you have to do an intimate procedure on a "demented" woman who fights you.

Makes me tear up too.

Specializes in LTC,Hospice/palliative care,acute care.
And all the while, this sweet demented woman was fighting us and crying out, "No, Father, no, please don't, Father, no, no, Father, stop ..."

The caregiver and I looked at each other over the bed and she said, "Whoever he was, may he rot in hell for all eternity." It still makes me tear up to think of her.

Think about that, too, when you have to do an intimate procedure on a "demented" woman who fights you.

That doesn't maker it any easier to deal with. I've cared for several LOL's who were apparently molested or abused in some way but almost all of them feel they are being attacked when staff is performing that type of procedure. The" demented" patient is actually reliving the experience.Think about some sedation prior and involve the family as much as possible.Most of these people should be on palliative care.The family needs to have a crystal clear understanding of the effect aggressive treatment has on this population.Our palliative care residents are seldom straight cathed unless retention is the issues.We'll do a clean cath-more then once I we need to rather then submit them to this.They aren't going out for acute care assessment and treatment unless they break a bone.

Specializes in Clinical Research, Outpt Women's Health.

It is horrible and it is kind of a nebulous area, but it has to be done and all you can do is try to provide as much privacy, comfort, and pain relief as possible and get it over as quickly as possible.

We all hate that stuff.

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