St. Elizabeth's

[DreameRN, BSN]

I took a travel position at CHI St. Elizabeth's in Lincoln, NE and for the first time ever I ended an assignment early due to unsafe conditions. Luckily my company and the clinical liasion they have are backing me up.

They have nurses signing and obtaining consent for the majority of procedures here (at least in ICU) , and when discussed with managment about why I refused to sign a consent for a procedure the doctor hasn't spoken to the POA about, I received back "we've done it this way for 40 years, and while I'm not saying practice doesn't need to change, that's the way we do it here". "if you don't sign consents, you are going to have a difficult time here, and someone else will have to sign your consents for you". :/

I could handle the short staffing, poor morale, and the tedious Meditech charting system, and the paper orders--all sometimes par for the course for traveling...and the staff RNs they do have are very nice, and friendly...But I felt that the expectation of me practicing outside my scope and having to obtain consents was not worth the risk of staying.

Traveler beware!

[NedRN]

You are not obtaining informed consent, you are witnessing a signature of the patient. If they do not feel like they have been informed, you need to call the doc to explain the procedure and the necessity to them before witnessing the signature. Their "practice" is almost certainly not reflected in their policies. I can certainly understand your lack of comfort, but was it a problem to call the doc? They know it is their duty to obtain informed consent. I do it almost daily, even with an already signed consent if the patient doesn't know what is going on. That is the crux of the matter, not a piece of paper. The paper merely documents the informed consent and I assess the patient first.

It is actually the duty of the patient to be involved in their plan of care and refuse treatment they don't understand or didn't agree to. Admittedly most patients don't understand their role or their illness is interfering with this, but we are the patient advocates. I think if the manager interferes with your ability to safely document care given to your patients, you should have taken it up with the CNO. That is a hard path for a traveler and likely would lead to your termination, but at least you know you did your part to improve patient care.

[DreameRN, BSN]

The situation was I was being asked to call the POA to get consent for a procedure. POA told me after I asked when I called him that the doctor hadn't actually spoken to him, but that he "trusted" us. I told the doctor that I didn't want to sign until he had actually talked to the POA--which he did not want to do. And didn't do. So I didn't sign. And they still wanted me to sign. It was at this point that I contacted management and was told this is how they did things.

The consent form read that " Dr. so and so has explained this...and I've had the opportunity to discuss.... etc. Based on that, I don't believe that the POA had risk/benefits/alternatives explained, and that's what I was signing. I have zero issue signing when the patient/POA says I have talked to the doctor and I have no questions.

[NedRN]

POA is power of attorney? In that situation, I would feel fine about signing that the POA agreed to the procedure. It is entirely up to them how they do their job. Forcing them to listen to the doc is not going to change anything, especially if they have talked to the doc at some point and were informed of the planned course of events and treatments and agreed. You are just again witnessing their signature (or telephone consent), not delivering informed consent. A statement from a POA or a patient that they trust the doc and don't want to know details is legitimate. I would simply document that conversation "trusted us" into the narrative notes.

No doubt others can weigh in on both sides of this, but you are also within your rights not to do something against your own judgement. That goes double if you believe the planned procedure has some unusually high risk to benefit ratio. Better than breaking written policy as well as your own best judgement. And if management was willing to delegate that duty to another nurse and you didn't believe your patient would be harmed, I would have let them!

I'm in the operating room but rarely have to deal with POA agents, generally family members are available (same issue I guess but generally family members want to be fully informed). But there are related issues about what one is willing to do in your own nursing practice. I recently had a charge nurse try to roll a patient into a room without required physician documentation and told him to circulate the case himself. He did! I do like to follow written policy. Consents do have tricky issues and really require a lot of judgement, and I'm not afraid to get a second opinion, and sometimes the signatures of two physicians if in my judgement informed consent is not possible and the procedure is best for patient.

[Argo]

As you described the situation I would not have a problem signing and charting a note to remind me of the situation if needed later on...