Patient Modesty

dutch92602 · Jan 22, 2008

Its not a right to make unreasonable demands which is what that is. The assumption seems to be that nakedness is the equivalent of a sexual display. In medicine that is almost never the case. Nakedness is part of what we do and it isn't something that we pay attention to.
In our rooms we wouldn't even consider a request to dictate the operative team. Asking that would probably be a huge red flag that you are not a surgical candidate. And yes you have the option of seeking other providers. To be charitable most of our patients have been in the medical system long enough that modesty is no longer a consideration.
Surgery is a team effort and you want your A team. Trying to dictate the team composition of something you know nothing about is almost certainly going to guarantee that your team is not composed of the optimal members in terms of experience or technical ability.
I've read some of your other posts. I understand that you feel that something wrong has been done. What you need to understand in medicine (and surgery especially) is that Nakedness is not the same as sex.
David Carpenter, PA-C

You have every right to your opinion. I agree with what you say in general, however, I suggest you read the regs hanging on the walls of your Atlanta institution and consult with the administration on the validity and legal ramifications of "Patients' Rights." Evidently, I can only assume that all of the laws and guidelines now in effect in this country in the healthcare setting was to allow the patient some personal choice for the beliefs including religious beliefs and this no doubt came from very unhappy patients and perhaps even a lawsuit or two. It used to be prior to these laws by JCAHO, HIPAA and the Patients Rights documents that it was only the way of the institution to provide care their way as you so state. I do not contend people are less than professional, talented, or are used to seeing nakedness. Those issues lie with the staff. It is the patient that has a few rights they are suppose to be able to exercise if they are not comfortable with it.

core0 · Jan 22, 2008

You have every right to your opinion. I agree with what you say in general, however, I suggest you read the regs hanging on the walls of your Atlanta institution and consult with the administration on the validity and legal ramifications of "Patients' Rights." Evidently, I can only assume that all of the laws and guidelines now in effect in this country in the healthcare setting was to allow the patient some personal choice for the beliefs including religious beliefs and this no doubt came from very unhappy patients and perhaps even a lawsuit or two. It used to be prior to these laws by JCAHO, HIPAA and the Patients Rights documents that it was only the way of the institution to provide care their way as you so state. I do not contend people are less than professional, talented, or are used to seeing nakedness. Those issues lie with the staff. It is the patient that has a few rights they are suppose to be able to exercise if they are not comfortable with it.

I assume you are talking about this:

http://www.hcqualitycommission.gov/final/append_a.html#chpt8

As far as I know there is no enforcement provision to these guidelines. CMS wants institutions to adhere to this but it is part of the overall rating of the institution.

In particular you are probably talking about this:

"Respect and Nondiscrimination

Consumers have the right to considerate, respectful care from all members of the health care system at all times and under all circumstances. An environment of mutual respect is essential to maintain a quality health care system. Consumers must not be discriminated against in the delivery of health care services consistent with the benefits covered in their policy or as required by law based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.

Consumers who are eligible for coverage under the terms and conditions of a health plan or program or as required by law must not be discriminated against in marketing and enrollment practices based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment."

There are two parts here. One part deals with insurance policies. The other part states that you cannot be discriminated against in the delivery of health care. This means that someone cannot refuse to see you because of a given characteristic. That does not mean that the institution has to follow all of your demands. Also generally to the extent that the "bill of rights" has any force, only organized characteristics are protected. For example a kosher diet would be an example of a protected area while a demand to ban meat from the floor because killing cows is murder would not be. The bill is about organized characteristics as opposed to non-organized personal beliefs.

I would agree that to agree to your demands and then not carry the agreement out is deceitful. The mistake is agreeing to the demands in the first place. Basically while this is a straw man argument what types of demands are realistic. If someone belongs to a religion that does not believe in the sexes mixing could they demand male blood only? At a certain point operational realities intrude into this argument.

You have the right to participate in your medical treatment. As a provider I have the right to refuse a demand that I deem unreasonable. If you don't like that you have the right to find another provider. As far as hanging on the wall, I can currently see two fliers for drug study. A grand rounds announcement and a pizza ad.

David Carpenter, PA-C

dutch92602 · Jan 23, 2008

I assume you are talking about this:
http://www.hcqualitycommission.gov/final/append_a.html#chpt8
As far as I know there is no enforcement provision to these guidelines. CMS wants institutions to adhere to this but it is part of the overall rating of the institution.
In particular you are probably talking about this:
"Respect and Nondiscrimination
Consumers have the right to considerate, respectful care from all members of the health care system at all times and under all circumstances. An environment of mutual respect is essential to maintain a quality health care system. Consumers must not be discriminated against in the delivery of health care services consistent with the benefits covered in their policy or as required by law based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.
Consumers who are eligible for coverage under the terms and conditions of a health plan or program or as required by law must not be discriminated against in marketing and enrollment practices based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment."
There are two parts here. One part deals with insurance policies. The other part states that you cannot be discriminated against in the delivery of health care. This means that someone cannot refuse to see you because of a given characteristic. That does not mean that the institution has to follow all of your demands. Also generally to the extent that the "bill of rights" has any force, only organized characteristics are protected. For example a kosher diet would be an example of a protected area while a demand to ban meat from the floor because killing cows is murder would not be. The bill is about organized characteristics as opposed to non-organized personal beliefs.
I would agree that to agree to your demands and then not carry the agreement out is deceitful. The mistake is agreeing to the demands in the first place. Basically while this is a straw man argument what types of demands are realistic. If someone belongs to a religion that does not believe in the sexes mixing could they demand male blood only? At a certain point operational realities intrude into this argument.
You have the right to participate in your medical treatment. As a provider I have the right to refuse a demand that I deem unreasonable. If you don't like that you have the right to find another provider. As far as hanging on the wall, I can currently see two fliers for drug study. A grand rounds announcement and a pizza ad.
David Carpenter, PA-C

Brilliant! I do not have the time at this moment to respond, but will plan to address your responses regarding these issue within a week.

Thank you so very much for your wisdom. I will not plan on visiting your state at all which would possibly subject me to entering one of the facilities for healthcare. In N.Y. a patient was always accomodated.

dutch92602 · Jan 31, 2008

creinkent, we are all professionals and must expose the patient in order to perform the surgery and ensure patient safety. there are some differences from place to place and dr. to dr. but, all is performed for the patient's procedure and safety.
the post sounds to me to be more in nature of a concerned patient instead of a student wanting to become a better patient advocate. just observation.
no offence is meant, i just recently was dealing with a patient on another board who was asking almost the same exact questions. we tried to answer at first but saw that she had not talked with the surgeon or facility about her concerns.
while patients have the right to know what is going to happen to them, there are things that are not addressed directly. if everything was addressed directly, we would have to have the patients come in a day early to explain exactly what is happening. questions such as: why is hibbicleans used instead of chloraprep, duraprep, iodine paint, iodine scrub or alcohol or any combination of physician choice? the use of what prep is a very small detail. as you can see, it wouldn't take long to fill an entire day of answering questions in detail.
it goes to say that what is considered an accepted standard practice may not sit well with all patients. explain the basics and if they still have questions, direct the patient to ask the physician.
the religious belief of the staff should be of little consequence to the procedure. we all have had training geared toward understanding the various patient religions, customs etc... we are to respect these beliefs and cultures.

i don't think patients want to know what kind of solution is going to be used!! come on. what they do care about is what is going to be done to their body and who is going to be doing what. maybe you could try to put yourself in someone elses' shoes. it all depends on if you are the person standing fully clothed or lying naked on a table with strangers of the opposite sex handling your genitals. it is everyday routine for or staff but not for a patient. how or staff feels about this has nothing to do with how a patient feels or how or staff thinks they should feel. read the bioethics discussion blog on patient modesty. you then realize this is a greater issue. the or seems to keep people in the dark about many things. it seems it is "they [patient] didn't ask, so we don't tell." did it ever occur to or staff that patients don't know what to ask but find out afterwards and then it becomes extremely upsetting. i am not a patient but an rn for many years. at one point or another in your lifetime either you or your spouse will be a patient. then the tables turn. :twocents:

Jarnaes · Jan 31, 2008

I'm an OR nurse and it is not standard practice to keep people unnecessarily exposed while in the OR. Our goal is to keep the patients covered and warm at all times in order to reduce any complications from hypothermia and to maintain the patient's privacy/modesty.

Anesthetic agents interfere with the function of hypothalamus and the body cannot compensate for hypothermia via central thermoregulation. It is easier to maintain someone's body heat than to try to warm them up once they have become hypothermic. It is just like in pain management; it is easier to prevent severe pain than to treat it once it occurs.

Hypothermia has been associated with an increased mortality rate, impaired renal function, cardiac arrhythmias, ischemia, decreased drug metabolism, poor wound healing and increased incidence of infection. And last but not least, hypothermia screws up the clotting cascade. Need I say more?

subee, MSN, CRNA · Feb 1, 2008

I don't think patients want to know what kind of solution is going to be used!! Come on. What they do care about is what is going to be done to their body and who is going to be doing what. Maybe you could try to put yourself in someone elses' shoes. It all depends on if you are the person standing fully clothed or lying naked on a table with strangers of the opposite sex handling your genitals. It is everyday routine for OR staff but not for a patient. How OR staff feels about this has nothing to do with how a patient feels or how OR staff thinks they should feel. Read the bioethics discussion blog on Patient Modesty. You then realize this IS a greater issue. The OR seems to keep people in the dark about many things. It seems it is "they [patient] didn't ask, so we don't tell." Did it ever occur to OR staff that patients don't know what to ask but find out afterwards and then it becomes extremely upsetting. I am not a patient but an RN for many years. At one point or another in your lifetime either you or your spouse will be a patient. Then the tables turn.

Dutch 92602: Where are you going with this? Are you afraid someone with think of your wife as a sexual object while she is in surgery? Would it be more right to tell every D & C patient that she will be placed in wide stirrups after she is asleep? Would that make anyone feel more comfortable? I think the problem is in your own mind...and pretty much ONLY in your own mind. The OR is not a sexy place: we're all under a lot of pressure to make this procedure a smooth and atraumatic one for everyone's sake - MOST OF ALL THE PATIENT! And keeping people normothermic is a ROUTINE part of the procedure. That means that NOTHING is uncovered that doesn't need to be. Believe me, having to look at the opposite sex's genitals during the day is not a perk. It just means that we have to be extra sensitive to the patient's anxiety and make sure that windows are covered, etc. So, Dutch 92602, look into yourself and ask why this is an issue for you? What are you angry about? I exhaust myself every day emotionally and physically to keep YOU happy. Give me a break!

dutch92602 · Feb 2, 2008

Dutch 92602: Where are you going with this? Are you afraid someone with think of your wife as a sexual object while she is in surgery? Would it be more right to tell every D & C patient that she will be placed in wide stirrups after she is asleep? Would that make anyone feel more comfortable? I think the problem is in your own mind...and pretty much ONLY in your own mind. The OR is not a sexy place: we're all under a lot of pressure to make this procedure a smooth and atraumatic one for everyone's sake - MOST OF ALL THE PATIENT! And keeping people normothermic is a ROUTINE part of the procedure. That means that NOTHING is uncovered that doesn't need to be. Believe me, having to look at the opposite sex's genitals during the day is not a perk. It just means that we have to be extra sensitive to the patient's anxiety and make sure that windows are covered, etc. So, Dutch 92602, look into yourself and ask why this is an issue for you? What are you angry about? I exhaust myself every day emotionally and physically to keep YOU happy. Give me a break!

If a patient goes to a doctors office and has a personal procedure they are alert and aware of who is handling them. All I am saying here is that people have varying degrees of privacy issues. If a patient is alert or asleep they might just care about who is handling them.

subee, MSN, CRNA · Feb 3, 2008

Well, we ALL care about the competencies of our caretakers. However, in 21st century America, gender isn't usually one of the variables that one should be wasting their time on. We have evolved (most of us) to a level of humanity that doesn't dismiss anyone because of race, religion, gender, etc. As a female, yes, I would prefer to have a female gyn. However, in the OR I want the sharpest practitioner and would drop my prejudiced attitude at once to get the best surgeon regardless of gender. In the OR, people function as a TEAM and the quality of the procedure is only as good as the TEAM. I wouldn't demand that a male surgical tech be pulled out of my room if he set up the case. He'd merely be displaced by a disgrunted person who was taken out of their room to be put in another room. Now the dynamics of the room have been disrupted by someone who wants to live in the 10 century. We're BETTER people than humans were in the 10th century - no more crusades, stake burnings, etc. We just don't dismiss someone's humanity because of their sex.

ewattsjt · Feb 3, 2008

When this thread was started there were several postings on some other forums and a couple of postings here in other threads that were locked. They were all patients wanting to have every aspect of surgery explained to them from the gowns being untied to prep solutions on the thigh for abdominal procedures, etc... The questions posed in the other threads, combined with this one was the reason for my remark about the prep. They did want every minute detail explained because it was their right to know.

Speaking of knowing; I see you don't know me at all because I have been in the patient's shoes. I have had several procedures on me including but not limited to a couple of spinal fusions. I trusted that the surgeon and the rest of the staff would be professionals. I also had female nurses to remove my catheters. They are all medical professionals. My reason for coming into the healthcare profession is because I want to help people as I was helped. I also do a lot of GYN because I lost both grandmothers to ovarian Ca. I realize it isn't about the staff but they have to be figured into the equation somewhere.

I also work in a facility that caters to giving female patients the choice of room staff. I think that it places the other patients at greater risk because when I am relieved from that room for an all female staff, I go to another room and pick up in their case (staff change). For some reason it isn't financially feasible to keep extra people staffed for such requests. So what if you are the patient who got a staff change because of it?

We do maintain modesty and in fact I am anal about it; more so than most my female counterparts.

I do have to say that I would not want to be in a room that the patient didn't want me in because it can only lead to problems.

dutch92602 · Feb 3, 2008

Well, we ALL care about the competencies of our caretakers. However, in 21st century America, gender isn't usually one of the variables that one should be wasting their time on. We have evolved (most of us) to a level of humanity that doesn't dismiss anyone because of race, religion, gender, etc. As a female, yes, I would prefer to have a female gyn. However, in the OR I want the sharpest practitioner and would drop my prejudiced attitude at once to get the best surgeon regardless of gender. In the OR, people function as a TEAM and the quality of the procedure is only as good as the TEAM. I wouldn't demand that a male surgical tech be pulled out of my room if he set up the case. He'd merely be displaced by a disgrunted person who was taken out of their room to be put in another room. Now the dynamics of the room have been disrupted by someone who wants to live in the 10 century. We're BETTER people than humans were in the 10th century - no more crusades, stake burnings, etc. We just don't dismiss someone's humanity because of their sex.

Why do you think that just because this is how you feel that every other person on earth feels the same? They don't. You are entitled to your opinion but it is how YOU feel not perhaps the way all patients feel. The silent majority accepts what happens and who does what under elective procedures. Silent compliance does not necessarily equate to informed consent and acceptance. A female knowing ahead of time that she will be spread eagle may not make her feel any better but if she also knew ahead of time that a male OR staff was going to do a 10 min cleanse MAY NOT be what she is willing to accept. This certainly does not mean he is not professional or trained. It just may not be what she is willing to accept. If she went to a doctors office and was alert she would not be willing to accept that. So I ask what the heck is the difference? Just because they call this the OR?

According to the AORN a patient has the right to interview all OR staff that will be involved in their care. I can only say patients are not aware of this. I am sure it never happens. Yes, we had an unsatisfactory experience and will never again eagerly accept surgery if it can be avoided at all costs. And, there will be many questions asked ahead of time. Well ahead of time. To the angry nurses that feel burned out perhaps they should get out of the OR. Don't you think all people feel this way that serve the public. Try being a clerk at XMAS time in a department store and putting up with people. Without the patient (for elective procedures), you and the surgeons wouldn't have a job. It truly is a customer service based business.

Go to the blog site by Maurice Berstein of UCLA entitled Bioethics Discussion Blog: Patient Modesty a more significant issue. There are nearly 800 comments coming from patients addressing this issue. The doctor suggests people (patients) need to SPEAK UP. Males have many issues with this and feel there is a double standard.

core0 · Feb 3, 2008

snip
According to the AORN a patient has the right to interview all OR staff that will be involved in their care. I can only say patients are not aware of this. I am sure it never happens. Yes, we had an unsatisfactory experience and will never again eagerly accept surgery if it can be avoided at all costs. And, there will be many questions asked ahead of time. Well ahead of time. To the angry nurses that feel burned out perhaps they should get out of the OR. Don't you think all people feel this way that serve the public. Try being a clerk at XMAS time in a department store and putting up with people.

I would be interested in seeing a reference on this. I really don't see how this is remotely practical. We frequently do cases that go across three shifts. Are we supposed to call in the people that are off so that the patient can meet them? Are we supposed to pull people out of rooms so that the patient can meet the lunch relief?. The patient meets the circulator, the surgeon and anesthesia. At least in my neck of the woods.

David Carpenter, PA-C

dutch92602 · Feb 3, 2008

I would be interested in seeing a reference on this. I really don't see how this is remotely practical. We frequently do cases that go across three shifts. Are we supposed to call in the people that are off so that the patient can meet them? Are we supposed to pull people out of rooms so that the patient can meet the lunch relief?. The patient meets the circulator, the surgeon and anesthesia. At least in my neck of the woods.
David Carpenter, PA-C

An AORN representative stated that to me in an email. Practicality of it?... that is another issue if it is a long case. Most I assume are not. But, that is what the AORN states as a patient right prior to surgery.