My Ethical Dilemma

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    I have recently moved to the OR. I am gaining confidence in my abilities and my team members. Though it has its ups and downs (my feet are killing me) I really like what I am doing. There is so much to learn and it is very exciting! On the down side, I have recently seen some things that I donít think are right.

    Twice in the past couple of months, we have had patients that asked specifically for certain things in our ASC which were granted by both management and surgeon. However, once they had their premeds, those requests were ignored by staff and once by the surgeon.

    I donít know if those were the only two incidents or if it happens more often. I am reluctant to ask colleagues since I am just getting to know these people. Since I was assigned to both cases, I attempted to advocate for the patient, but was reminded that ďwhat the patient doesnít know wonít hurt themĒ and that I should focus my attention elsewhere.

    Should I bring this to the nurse managerís attention or disregard, focusing solely on the patientís outcome? Does this happen frequently and is typically in the best interest of the patient, or is it something that we shouldnít do? My belief is that if management/surgeon makes a promise to the patient AND it is medically appropriate, we should not disregard once the patient has been medicated. Am I wrong?
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  3. 10 Comments so far...

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    I don't think you're wrong, but I think how you handle it might depend on the specifics of the situation. I can also understand that you might not want to post too many specifics to a widely read online forum though.
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    It's hard to answer without specifics, but if it's something that could in anyway be considered fraudulent, then it needs to be reported immediately. If it's other stuff like telling the patient that they won't have a foley, but you know they will, then I would go to the manager with your concerns. If the manager says it okay to tell patients untruths, then that probably means they believe it's okay to tell you untruths too. Consider a teaching hospital with residents, because the relationship between nurse and doctor is different, and we don't let them get away with that kind of stuff.
    sarath likes this.
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    There was nothing fraudulent concerning charting, but it was beyond telling them they wouldn't get a foley. One was promised a specific make-up of the surgical team and the other was promised a specific MDA. There was nothing that would have affected the patien'ts outcome, and they were none the wiser. I don't believe the boss would approve of this, so I will speak to her. I would rather not simply disregard something I know is wrong. Thanks for the advice.
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    Quote from sarath
    There was nothing fraudulent concerning charting, but it was beyond telling them they wouldn't get a foley. One was promised a specific make-up of the surgical team and the other was promised a specific MDA. There was nothing that would have affected the patien'ts outcome, and they were none the wiser. I don't believe the boss would approve of this, so I will speak to her. I would rather not simply disregard something I know is wrong. Thanks for the advice.
    Is this something like a patient who said "I don't want any residents involved in my case"? I went to college with someone whose parents sued her surgeon because they claimed that he promised no one would touch her but him. Evidently the surgery was actually performed by an associate. I have no knowledge of the outcome of this case though knowing what I know about the surgery she said (because I had the same surgery), some of the long-term issues she experienced are known complications of said surgery, regardless of who performs it so I'm doubtful that they got what they were hoping for in court. It would be very hard to prove "the doctor promised me that only he would operate on me, that no residents would be involved in my case, that no med students would observe, etc." when in the fine print on surgical consent forms it often explains that "this is a teaching hospital, residents and medical students may be involved, etc etc etc." and the hospital will be able to produce a signed consent.
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    We are an ASC, not a teaching hospital. Our consent form two pages and very specific, having blocks for both the attending's name and his/her assistant (SFA or other). The second page is for the MDA/CRNA, also with a block for the names of either MDA or CRNA, and here is where the issue arose in the one case.

    Mr 'X' wanted a specific MDA he had been with on a case prior to this one. The schedule had been worked, and Dr 'Q' met with him in holding, but after he received his premeds, the MDA left him in the care of a CRNA. Again, the patient's outcome was great and he never knew about the switch.

    What I am concerned with, in both cases, if how the patient ever finds out. In your response, you said they sued. How did they find out? Did someone tell them or did they access their records? Shouldn’t the boss know about this beforehand if it somehow surfaces?
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    Was the MDA the supervisor for the CRNA? Unless the request was specifically for MDA only, I would think the MDA would be "technically" still taking care of said pt.

    The other case would depend on how long procedure lasted, was this just relief staff or they never put in who was promised? As an OR nurse I generally ask for certain staff, but I don't want my peeps to miss lunch or break just because they are in my case. If someone just flat out lied to the pt's I would casually talk to your boss about it. Put it like you are asking for clarification not snitching, :-)
    4100RN and sarath like this.
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    On any given day, there are some MDAs supervising and some who are not. In this case, the patient asked for this particular MDA only and his surgeon also wrote "Dr Q - only" on the surgery order form.

    In the other case, there was no relief staff - we only had an hour block. To use your phrase, "someone flat out lied to the patient". Pretty much the same circumstance - the team make-up was specified on the surg order and was expressed clearly by the patient. This is what is so frustrating - it was the surgeon who brought an additional tech into the OR.

    I like your advice. I will casually bring it up with the boss. She is very strict, but easy to talk to. Thanks!
    SandraCVRN likes this.
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    Quote from sarath
    We are an ASC, not a teaching hospital. Our consent form two pages and very specific, having blocks for both the attending's name and his/her assistant (SFA or other). The second page is for the MDA/CRNA, also with a block for the names of either MDA or CRNA, and here is where the issue arose in the one case.

    Mr 'X' wanted a specific MDA he had been with on a case prior to this one. The schedule had been worked, and Dr 'Q' met with him in holding, but after he received his premeds, the MDA left him in the care of a CRNA. Again, the patient's outcome was great and he never knew about the switch.

    What I am concerned with, in both cases, if how the patient ever finds out. In your response, you said they sued. How did they find out? Did someone tell them or did they access their records? Shouldn’t the boss know about this beforehand if it somehow surfaces?
    I am honestly not sure of the details. It was someone who I knew by association in college but she was roommates with one of my good friends so that's how I became familiar with the story. It was something that had happened 10 years earlier and the case was still being dragged through the courts. The surgeon in question ended up dying before anything happened and I believe the case was dismissed because the courts found that families/patients cannot sue for outcomes that can happen with this type of surgery regardless of who performs it. (It was something like surgery on one side of the brain caused weakness and peripheral vision loss on the contralateral side which is a known complication and was likely listed on the consent form under possible risks.)

    IMO, it's wrong for a surgeon to promise a patient that only a certain anesthesiologist will take the case when the surgeon probably does not know the anesthesiologists' schedules/plans. Do you not have separate anesthesia consent forms?
    Rose_Queen likes this.
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    Quote from KelRN215
    IMO, it's wrong for a surgeon to promise a patient that only a certain anesthesiologist will take the case when the surgeon probably does not know the anesthesiologists' schedules/plans. Do you not have separate anesthesia consent forms?
    I agree. Surgeons have no business promising something they have no control over (including a perfect outcome as a result of the surgery).

    We do have some patients who request a certain anesthesia provider. A note is made in the booking, but nothing is ever promised to the patient. Granted, most of the requests come from staff members, either for themselves or on behalf of their family members, and the anesthesia providers are usually pretty flexible about making themselves available.

    Our surgical consent is completely separate from our anesthesia consent, and the surgeon has very little influence over anesthesia decisions (even cases where the surgeon asks for a certain type of anesthesia can't always follow that request based on patient status) and anesthesia has no influence over surgical consent.


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