Arizona Nurse's License Threatened by Doctor After Providing pt education - page 9

by lil miss

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the email and arizona state board of nursing casethis is a (must read) e-mail that was passed to me from echo heron. @echoheronauthor hello ms. heron, my name is amanda trujillo. iím a registered nurse of six years ,... Read More


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    An RN ( putting aside the fact that she has an MSN, an advanced practice degree) enters a patient's room after report, it states she is working the 7a-7P shift, I am assuming she is doing bedside nursing( Kudos to her for doing bedside with an MSN- I sure wouldn't) goes into this patient's room, end stage liver disease awating transplant eval. She stated she is specialized in end of life/pallative care; so RN does nursey thing-' how are you/' and the patient answers or acts in a way that causes the RN to question the patient's understanding of this eval and provides( professional obligation is more like it)to ask about her impending transplant eval- Pt answers in such a way that RN assesses( again professional obligation) does this patient understand what this process is? It is the RN"s legal obligation to answer that patient's questions or if the RN doesn't know to say I don't know, I will find the answers for you and get back to you. I think any RN with many years of experience( minus the MSN) would have done the same thing this MSN,RN did- answer the patient's question and given the patient the hospital approved teaching tools to supplement the nurse-patient interraction and document the discussion and in my experience, I've also had to document the name of the hospital 'teaching tool'( pamplet or booklet; example: "So You Have a Pacemaker, What Now" or 'Facts about CHF", or "Preparing for Open Heart Surgery" or "Coumadin Therapy")

    "What would a reasonably prudent nurse do?" I think that is the bottomline question the board of nursing will judge her on. Not that riduculous statement from her NM. "you messed up all the surgeons hard work".

    This entire episode is absolutley poposterous, in the year 2012. If I were that RN- after this is all over I would sue the pants of that surgeon for at the VERY LEAST- pain and suffering, not to mention Mental/ Emotional/Financial/Professional Abuse and Defamation. I would clean him out of everything he owns. Car, house, bank accounts, stocks bonds portfolio. He would be adversizing in the local newspaper and a sign on every telephone pole for organs to transplant.
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    Quote from Hampter320
    as far as everyone saying she was just advocating, educating, blah blah blah... We all know this wasn't a simple case of the nurse giving the patient some pamphlets and saying "what do you think?" No, this is all going down because she took matters into her own hands and used her medical judgement (which she wasn't qualified nor allowed to do in the system) and determined the patient wasn't a candidate for the surgery. Then proceeded to give advice (possibly wrong? who knows) to sway the patient's decision towards not having the surgery. She did not simply hand the patient hospital-pamphlets and say "I will have the attending come explain the risks and benefits of the procedure in the morning." It is not her job to tell the patient what medications and how long he'll have to take them post-transplant. It is not her job to tell the patient what his prognosis is post-op. I'm sorry, but if somebody is going to tell me about my upcoming transplant or whipple's procedure or bypass surgery, I want it to be the surgeon or MD who is responsible for actually performing 1000s of said procedures. Not the family practice doctor who sees me as an outpatient for my yearly physical, not the dermatologist who did a skin check for me last year, and not the nurse who manages my care on the floor pre and post op. This is the problem with society today... nobody understands how much they don't know. Everyone deems themselves an expert in everything in the day of the internet regardless of their profession.

    Again, this all could have been avoided if she simply told the day nurse to give the MD a call and say they don't feel the patient is well informed, can you please have a discussion when you come back to see him. The surgery wasn't the following day. The situation wasn't emergent. And this is NOT a matter of a doctor just wanting to make money from a surgery. As someone already pointed out, the risks and costs to the hospital for a transplant FAR outweigh the actual monetary gain from performing the procedure. This is why transplants are not done at small community hospitals or even every larger hospital. This is not about the big bad MDs and their struggle for power, this is not about the hospital wanting to make money. We've only heard one side of the story, and are providing biased commentary based on the nature of this message board.
    To begin with, Nurse Trujillo didn't make ANY actual medical desicions. She didn't say, or write, anywhere that the patient was not qualified for transplant. She merely figured out that the patient had no idea what she was heading into, and just tried, in my personal opinion, WAY too hard to mend the situation.

    If you don't know, education of transplant patients is NEVER done by handing them leaflets and asking what they're thinking about it. The transplant "boards" realize very well that if they give a liver to a patient "X", they sentence patient "Y" to slow and painful death, and they are determined not to waste any of the precious organs they get, so education of the patients is a huge priority for them. It is always done precisely the way Nurse Trujillo did it; and it is done mostly by transplant coordinators, who are RNs. It includes discussion about every single thing you'd mentioned: risks, benefits, pre-post course and so forth.

    I personally cannot completely agree with what Nurse Trujillo did because of screening/ providing education for that particular patient was the job transplant care team was better qualified for. The patient was just admitted for evaluation; most probably she was hours from meeting transplant coordinator who would tell her all the same things "officially" and that doctor would be called by her for the very same hospice consult because patient would refuse to sign all the paperwork obliging her to agree to regiment which looks pretty much like one for paroled minors' sex offenders (mandatory living where they're told, drug/ alcohol screens, no traveling without permission and so forth). I also would like to know if Nurse Trujillo told the patient about pleasanties of dying from liver failure, and if she had special training to confirm her multiple "specializations" in cardiology, gerontology and palliative care. But I don't doubt that, fortunately or not, doctors are rather rarely present full truth to patients, that they systematically avoid discussions about end-of-life, palliative and alternative care options, that they do sacrifice patients' rights in the name of their professional ambitions, and that medically unwarranted treatments and surgeries are more than common nowadays in this country, placing a lot of people through incredible sufferings and leading our country to actual backruptcy. Nurse Trujillo's actions could be poorly timed, her judgement was far from ideal (after all, she didn't seem to realize that all patients heading for transplant are dying, by definition), but her actions were pointed toward advocating for the right of the patient to refuse treatment and to know what's ahead of her - all the knowledge her doctor(s) withheld from the patient, although theoretically it was their responcibility. Would YOU like to see your doctor (who did perform those "1000s surgeris" to just tell you "you're gonna to be fine, buddy" and then be exposed to the process of slow and artificial dying in an ICU bed, or you would prefer someone else to tell you the truth from the beginning, and make your own choice?
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    Quote from KatieMI
    To begin with, Nurse Trujillo didn't make ANY actual medical desicions. She didn't say, or write, anywhere that the patient was not qualified for transplant. She merely figured out that the patient had no idea what she was heading into, and just tried, in my personal opinion, WAY too hard to mend the situation.
    What she did was sway the patients decision based on her giving information that may or may not have been accurate. Mending the situation should have involved handing the patient some pamphlets and saying "Dr. X will see you in the morning to answer any further questions you may have." If a patient is admitted with a COPD exacerbation, is it my duty to tell them "your quality of life is going to be poor from here on out, perhaps you should look into hospice"? No, it's not. Everyone wants to feel important and like they are doing something meaningful but there are lines that should not be crossed. Want to explain to a patient what having an MRI entails? Great. Want to explain to a patient why they can't eat anything the night before a colonoscopy and why they have to drink something that will make them crap? Terrific. But as a floor nurse, it is not your job to give the patient a prognostic outlook on the rest of their life regardless of how many initials come after your name or how much you think you know about their condition.


    Quote from KatieMI
    all the knowledge her doctor(s) withheld from the patient, although theoretically it was their responcibility. Would YOU like to see your doctor (who did perform those "1000s surgeris" to just tell you "you're gonna to be fine, buddy" and then be exposed to the process of slow and artificial dying in an ICU bed, or you would prefer someone else to tell you the truth from the beginning, and make your own choice?
    And this is where your bias shines through. You have no idea what the doctor did or didn't tell the patient. You also have no idea what the nurse told the patient and whether or not it was factual. So how exactly can you take sides? Do you really believe the doctor told the patient there would be no complications and everything would be fine? Seriously? You don't know what he said. The surgery wasn't taking place the following day, there was no urgency in any of this. How do you know the patient didn't misunderstand what the doctor told her and it would've been easily cleared up the following day? You are taking sides just for the sake of taking sides, because she shares the same occupation as you.
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    [QUOTE=Hampter320;6123323]What she did was sway the patients decision based on her giving information that may or may not have been accurate. Mending the situation should have involved handing the patient some pamphlets and saying "Dr. X will see you in the morning to answer any further questions you may have." If a patient is admitted with a COPD exacerbation, is it my duty to tell them "your quality of life is going to be poor from here on out, perhaps you should look into hospice"? No, it's not. Everyone wants to feel important and like they are doing something meaningful but there are lines that should not be crossed. Want to explain to a patient what having an MRI entails? Great. Want to explain to a patient why they can't eat anything the night before a colonoscopy and why they have to drink something that will make them crap? Terrific. But as a floor nurse, it is not your job to give the patient a prognostic outlook on the rest of their life regardless of how many initials come after your name or how much you think you know about their condition.[QUOTE=Hampter320;6123323]

    Every single piece of information you give to a patient can "sway the patient's decision". Your patient asked you about colonoscopy prep, you give him a booklet. The patient reads it, asks you if he really has to be NPO, drink that stuff, etc. After you answer "yes, that's how this thing goes" the patient says that he doesn't want to have colonoscopy anymore because he'd had lumberjack breakfast every day for the last 68 years of his life. You, and then doctor's explanations go nowhere, the patient leaves the hospital. In 18 months he comes back with inoperable colon cancer.
    So, can it be said that yours, or doctor's, or the booklet author's "actions" somehow led to this unfavorable outcome? One may argue that if you'd withhold all "negatives", which are all subjective, then the patient would stay, get it done and the tumor would be removed in time, etc, etc. And this one well might be right, because there are people who for some reason love to flush their intestines like that and claim that they feel 20 years yonger afterward, and this information is just as accurate as description of colon prep as "pure h***".
    BTW, if you think that "giving prognostic outlook" is not what a floor nurse can do without crossing lines, then should an RN working in inner city OB clinic be disciplined for saying, for example, "dear, you and your baby may got into really big trouble very soon if you continue to miss your sugar checks and insulin shots"? If so, what she should do instead, if this clinic doesn't even has a doctor in staff?




    [QUOTE=Hampter320;6123323] And this is where your bias shines through. You have no idea what the doctor did or didn't tell the patient. You also have no idea what the nurse told the patient and whether or not it was factual. So how exactly can you take sides? Do you really believe the doctor told the patient there would be no complications and everything would be fine? Seriously? You don't know what he said. The surgery wasn't taking place the following day, there was no urgency in any of this. How do you know the patient didn't misunderstand what the doctor told her and it would've been easily cleared up the following day? You are taking sides just for the sake of taking sides, because she shares the same occupation as you[QUOTE=Hampter320;6123323].

    Here's a good book for you about the high art of making conclusions on the base of both facts and possibilities:





    Amazon.com: sherlock holmes complete collection: Books


    I pretty much know how this system works. I also saw things like this done, and so I can surmise with reasonably high probability what really happened there. As you could see, I am not completely on the Nurse Trujillo's side. I wrote that by my opinion, her actions were less than completely appropriate, and she wasn't the best available person to do the job.
    BTW, in my book, if patient is scheduled for something, and has no idea what this "something" is, why it got to be done, and what he/she may expect as a result, then whoever put him/her there didn't do a nice job, whatever letters might follow his name.And i personally do not mind to pick this type of slack if I really know how to do it right. If I don't, I find someone else.
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    Quote from KatieMI

    Every single piece of information you give to a patient can "sway the patient's decision". Your patient asked you about colonoscopy prep, you give him a booklet. The patient reads it, asks you if he really has to be NPO, drink that stuff, etc. After you answer "yes, that's how this thing goes" the patient says that he doesn't want to have colonoscopy anymore because he'd had lumberjack breakfast every day for the last 68 years of his life. You, and then doctor's explanations go nowhere, the patient leaves the hospital. In 18 months he comes back with inoperable colon cancer.
    Saying a patient should be NPO - that is stating a fact that applies to any patient going for a colonoscopy. Telling a patient they will have to lay still for 30 mins for an MRI holds true for any patient undergoing that test. That is not giving a patient their specific individualized medical prognosis or telling them they are a candidate for hospice if they choose not to have the colonoscopy or MRI.



    Quote from KatieMI
    So, can it be said that yours, or doctor's, or the booklet author's "actions" somehow led to this unfavorable outcome? One may argue that if you'd withhold all "negatives", which are all subjective, then the patient would stay, get it done and the tumor would be removed in time, etc, etc.
    You are making things up. Nobody ever suggested withholding negatives, and you don't even know if the doctor in this case even withheld anything vs. the patient not understanding the procedure. The difference between a booklet explaining something and a doctor who is knowledgeable in transplants is that a booklet gives general guidelines that can be applied to the majority of patients. A doctor can individualize for each patient, discussing their prognosis based on comorbidities and staging. A floor nurse has no role in this. I can admit that.



    Quote from KatieMI
    And this one well might be right, because there are people who for some reason love to flush their intestines like that and claim that they feel 20 years yonger afterward, and this information is just as accurate as description of colon prep as "pure h***".
    There are also people who get off on drinking someone elses vomit (see a disgusting website that got pretty famous 2 years ago), people who think homeopathy works, and people who think vaccines cause autism. What's your point? I've seen 1000's to 10,000's of patients in my lifetime, and have never met a patient whether it be in the hospital or in the outpatient setting who looked forward to the bowel prep and stated they feel 20 years younger after a night filled with no sleep, explosive diarrhea, and a serum potassium of 3.0 the following morning. Get real.


    Quote from KatieMI
    BTW, if you think that "giving prognostic outlook" is not what a floor nurse can do without crossing lines, then should an RN working in inner city OB clinic be disciplined for saying, for example, "dear, you and your baby may got into really big trouble very soon if you continue to miss your sugar checks and insulin shots"? If so, what she should do instead, if this clinic doesn't even has a doctor in staff?
    You're grasping at straws.

    A) These events did not happen at an inner city clinic. There were plenty of well qualified physicians to give the patient a detailed, individualized step by step run down a potential liver transplant. The nurse should have called for a physician to discuss the procedure with the patient. Period.

    B) Telling a patient to follow up on basic healthcare exams and maintenance is not giving them a prognosis or suggesting hospice. I'm sorry if you can't comprehend this.





    Quote from KatieMI
    I pretty much know how this system works. I also saw things like this done, and so I can surmise with reasonably high probability what really happened there.
    Ah, so then please tell us exactly what the doctor told the patient, and what the nurse told the patient, and what exactly the patient didn't understand about the procedure.


    Quote from KatieMI
    BTW, in my book, if patient is scheduled for something, and has no idea what this "something" is, why it got to be done, and what he/she may expect as a result, then whoever put him/her there didn't do a nice job, whatever letters might follow his name.And i personally do not mind to pick this type of slack if I really know how to do it right. If I don't, I find someone else.
    The above is a legitimate opinion to hold, and I share the same thought. But we cannot jump to take sides here just because she's a nurse. You are flat out assuming that the patient knew nothing about what a liver transplant entailed, didn't know why she was getting the procedure, etc... I highly doubt this was the case but if it was, then the physician should be called back in to further explain. If you want to "advocate" for your patient, then you can be present in the room with the patient with the physician to clarify.
    ProArizona likes this.
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    Wow. Hot topic. Here in TX a MD is legally obligated to obtain informed consent, where the nurse is the witness to signature of said consent. This often gets us a blurry line; to be safe, if a patient has any question or concern, the nurses' duty is to contact the MD to clarify for the patient. That being said, if I called a doc to tell him/her that the patient had concerns relating to said procedure/treatment/medication, the docs I work with would oblige by further discussing with said patient. It is my duty to document said concerns in the medical record, hospital-endorsed educational material given, and my action taken and the MD's response/orders/etc.

    This nurse simply did her duty to a patient, a MD had a fit, and the hospital responded. The one thing to remember about end-of-life issues is simply that your dead patient will never sue you for following their wishes but the guilt-ridden family still alive will always sue to prove their love. [Not that all lawsuits are misguided...but we've all seen the family drama b/c grandma's dying and no one's seen her in 3 years besides the nursing home staff/home health aides.]
    SE_BSN_RN, cindjo717, tewdles, and 1 other like this.
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    So to hell with the patient and do your real job: smile, kiss ass, chart like Charles Dickens.

    That's what I feel my job is coming to. I do not take care of patients anymore. I take care of Doctors, Senior Nurses-better not offend one of them or they write me up to the - Nurse Managers, Nursing Directors, Chief Nursing Officers (all of whom prance around in their high heels and designer bags and haven't done bedside care in ages), Administration, the Joint Commission, CMS, DHS, etc etc

    Why are we here? to document? just take the flipping patient out of the equation and have them taken care of by robots while we write about it.

    That is what happened here. one of "us" got their panties in a twist because "nurse Trujillo has a Masters and thinks she's better that everyone else we'll show her" someone didn't like it when one of "us" does her job.

    I am so sick of this shite and sick of this thread. We have truly lost it as a profession. We are done. there is no hope. We are working class schmucks who will never be recognized by any legitimate profession because we are at each others throats and act like sorority sisters.

    And yes I wrote this after a bad night at work. Every night is a bad night, no matter how "easy" it is. that is because we have lost our soul and mine is decaying as well. I sincerely wish that I had become an accountant, or a lawyer. At least it's honest work

    ps: this was not a reply to anyone in particular. I value the opinions I disagree with as much as the ones I agree with. They offer differing perspectives which is important in theory. I am just really - upset (literally almost in tears and wish I could support my family on minimum wage)- about where healthcare in general is going (and I am not a rabid anti-ACA person, I actually support single payer) It just seems with more regulation that is what becomes the focus of attention and effort and the patient gets lost in the shuffle, we are literally killing people that could live and saving people who are dead. I wanted to save the world when I started eight years ago and now I am just used to save money, and I cooperate because I need the job. I open my big mouth sometimes and this (Nurse Trujillo's experience) is exactly where it gets me ...that much closer to the unemployment line. I wish I could tow the corporate line but its wrong and I feel my humanity slipping away everytime I acquiesce to another corporate demand.
    Last edit by gypsyd8 on Feb 8, '12 : Reason: grammar/syntax/disclaimer
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  8. 3
    gypsyd-

    that was a great post. You put it all very well. I'm right there with you. I think and hope there is alot of us nurses out here in your corner and feeling the same things.
    SE_BSN_RN, barbyann, and lindarn like this.
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    I am really, really glad there is a Transplant Coordinator RN working on all the transplant cases I am involved in.
    Fyreflie, tcvnurse, and lindarn like this.
  10. 1
    Thank you for writing this. I am sorry that you are having to face this.

    I will say that not every hospital is like this. I've been where you are and moved to a different facility where I feel valued and feel like I make a difference. I also moved away from bedside care, so I am not sure which moved caused my greater job satisfaction.

    I can honestly say I love what I do now. I enjoyed bedside care but always felt challenged and felt like I could never do as much as I wanted for the patient.
    lindarn likes this.


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