what's the best ethical resolution?

GirlArcher · Feb 22, 2004

First and foremost, we, as nurses, are patient advocates....if no one will stand up for the patient, then who do they turn to? If the patient and the family were against the procedure, then it should never have been done. That is how I feel about it and I have refused to do a procedure that was ordered by a doctor....the family and patient didn't want it done and there wasn't a consent signed, so it didn't get done....I called the doctor and let him know my reasons for not doing it. He later came up to the floor and tried to talk the family into it....they again refused and it was dropped. We need to put the patient and the family first, before a doctor's order.

Katnip, RN · Feb 22, 2004

Agree with Girl. You cannot legally force a procedure on a patient. The nurse and the doctor can be in deep doo-doo over this one.

RNPATL, DNP, RN · Feb 22, 2004

Hi all,
MAy i have some opinions from anybody for the scenario below;
A 65 years old female was admitted to hospital after a fall. She was diagnosed with left CVA stroke. Patient refused to eat and drink and was in a denial stage for her condition. She tried to eat but unable to swallow properly, therfore, lead her to deny all food and drink served a couple of days. Intake / output chart showed unacceptable result.Doctor in charged thus ordered a ryles tube insertion for her to replace oral intake.

Upon insertion, patient refused the procedure, family members were contacted to persuade patients to undrego the procedure but they were not supportive of the idea as they feel that the patient was capable of ingesting orally.

Despite the family and patient disagreement of ryles tube insertion, the nurse incharge proceeded with the Dr's order.

What's your solution is your patients doesn't want to be tube fed and yet the dr's order is to do so.

Wow, what an ethical issue this is! I would first determine if the patient was truly competent to make this decision and that the stroke had not impacted upon her ability to make logical decisions. Next, I would also determine if the patient had any advance directives and had appointed a health care surrogate. If the patient is refusing the treatment, that refusal is her right as a competent adult and should NOT be forced upon her.

I agree with the previous poster that as nurses, we MUST advocate for our patients. A big part of being an advocate is to work with the patient and the family to ensure that the patient's wishes are honored .... this is especially true if the patient's ability to reason and make decisions has been impacted by the stroke. The nurse in charge should have never placed that tube for artifical feeding without the direct consent of the patient or in the absence of the patient's ability to consent, the next of kin. Shame on her! The mere fact that the family believes the patient can swallow ... is an example that the family does not have enough information about their mother's condition. Did the patient have a swallow study? Was the family informed of the results? Was the patient informed of the results?

These situations are tough ones to work with. In my hospital, we have a very active ethics committee and we work on these types of issues to ensure that the patient receives care and services in accordance to their wishes. I would certainly recommend that you bring this case before your ethics committee and let them review it to ensure that the patient is being respected. Good luck.

Trauma Columnist · Feb 22, 2004

I would delay the procedure in order to get neuro-psych eval and then go from there. I would NEVER, EVER force a procedure on someone who I judged to understand the WHY of the procedure.

BadBird, BSN, RN · Feb 22, 2004

As I see it that nurse could be charged with assault. Patients have a RIGHT to refuse treatment if they are of sound mind and since the family agreed with the patient then forcing a procedure on her was completely inacceptable.

jnette, ASN, EMT-I · Feb 22, 2004

As I see it that nurse could be charged with assault. Patients have a RIGHT to refuse treatment if they are of sound mind and since the family agreed with the patient then forcing a procedure on her was completely unacceptable.

ITA. !00%.

nurseygrrl, LPN · Feb 22, 2004

I wouldn't have pushed that tube on that poor woman. Maybe she just needed some time and a little counselling?

Tweety, BSN, RN · Feb 22, 2004

Perhaps they would have agreed to some hydration until they had time to process the information. I agree it was inappropriate to do that.

We had a similar situation on the neuro unit I used to work on. Patient and family refused feeding. One of the nurses refused to take care of the patient because "I can not ethically partake in the starvation of a patient". I had to reassign the patient.

Can be a little nerve wracking.

leslie :-D · Feb 22, 2004

first thing that comes to mind is that this lady has just suffered a stroke and is probably unable to swallow and needs a speech therapist to do an eval. if it's found that this lady does suffer severe dysphagia or has no gag reflex then the remaining choices are a fdg. tube or comfort measures. sometimes we place a midline and keep them hydrated to monitor for any return of function. this family needs to hear from a specialist that yes, she can swallow but is refusing; or no, she is totally unable to swallow w/o the risk of aspiration. once the facts are known, decisions can be made accordingly. but if this lady has been making decisions for herself up until this point, then she probably will still maintain that right to do so, unless psyche comes in and deems her 'incompetent' secondary to neurological or emotional/mental trauma. but what seems pretty black and white to me is that this lady's rights were invaded, and there were other interventions that should have been applied.

Havin' A Party!, ASN, RN · Feb 24, 2004

...The nurse and the doctor can be in deep doo-doo over this one.

Also the facility.

lady_jezebel · Feb 24, 2004

The pt refused the procedure. You can't ethically/legally force this on the pt. Therefore, you must 1) first talk to the doc again, relate what you know, and ask for a nutrition, speech therapy, or other relevant consults, and 2)go up the chain of command if this doc does not revise her/his plan -- go to the attending, house officer, whomever. Finally, report all of this to the head nurse & the nurse manager, for ultimately it may have to be taken to an ethics board. Also, remember to document everything.