Consents When Under The Influence

Nurses General Nursing

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I had a pt today with a really gnarly compound dislocation/fx that I knew from the get-go would be sent to the OR. By the time I got the wording of the consent from the surgeon the pt had been medicated with two different narcotics. I've never been comfortable getting a consent from a medicated pt but was always admonished that if the pt was still able to understand the consent and the reasons for it, I could have them sign. To protect my own butt I've always had a relative co-sign, if at all possible. The ER doc saw me doing that today and made fun of me.

Another problem with consents. We transfer all of our pts that need a psych eval because we don't have mental health. I never get a psych pt on a hold to sign a consent because it's being done against their will. I figure if they're on a hold because they're a danger to themselves, they are not capable of consenting. Other nurses tell me I'm being silly, that they can still consent.

What do you guys do? Should I stick to my guns and continue my practice, or should I give in?

I never understand why the medical profession handles psych pts as if they are the scourge of the earth. According to the psych pts I have worked with, one of the things that upsets them the most when they come to the hospital is how they are treated less than human. Granted, if they are delusional, homicidal and paranoid, you are probably not going to get far with them nor would it be safe to give them a pen.

But even on an involuntary hold, the MD *should* explain that they are dangerous to self or others and are being placed on hold, at which time they can be asked to sign into the psychiatric unit for their own protection. They may well refuse, but ED has done its duty to ask for the signature.

I have had to de-escalate many psych pts on the unit after they were treated without dignity in the ED.

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Specializes in FNP, Peds, Epilepsy, Mgt., Occ. Ed.

My question was about the legalities of obtaining a consent from an impaired pt, be it due to narcotics or psych, even if the pt can verbalize understanding. The docs say I'm too anal about it. Am I or not?

I don't think you're being too anal.

I know that "back in the day" in the hospital one of our pre-op items we had to do was to check that there was a signed consent on the chart before the patient got any preop medication. If the patient had the preop morphine, for example, and the consent was found to be unsigned, the surgery was postponed. The nurse in that situation was in trouble- not for not getting the signature, but for not notifying the surgeon that it had not been done.

I don't know if the legalities have changed, or if it's just become habitual to get the signature regardless.

I think your policy of getting someone else to sign is a good one. It might just save your behind and the doc's, too, some day. Never mind what the doc or your co-workers say!

Can't you just hear the lawyer telling the jury that this poor patient never agreed to have this surgery done because "they made him sign it after he was all drugged up and he didn't know what he was doing? Here this poor man woke up one day with his left testicle missing and he never agreed to have that done!" :D

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Specializes in 5 yrs OR, ASU Pre-Op 2 yr. ER.
By law you are not obtaining consent when signing the patient signs the consent form. The DOCTOR has to be the one that obtains the consent, your signature merely states that you witnessed the patient sign the consent. UNDER NO CIRCUMSTANCES should you be the one obtaining consent. The courts would go after you if something bad happened during the procedure.

:yeahthat:

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never obtain a consent FROM A MEDICATED PATIENT. as for psychiatric patient, i believe it is only acceptable during their LUCID INTERVAL.

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My question was about the legalities of obtaining a consent from an impaired pt, be it due to narcotics or psych, even if the pt can verbalize understanding. The docs say I'm too anal about it. Am I or not?

No, you are not being anal, you are being smart! Regarding the psych patient consents, I have to agree with a couple of the other posters about at least giving the patient the option of consenting. They deserve that dignity and are all too often stripped of more dignities than most patients with other medical conditions. It is sad how the medical community tends to treat them as if they don't have a real medical condition :( Ok, off topic there ;)

I recently had such a situation with a medicated patient and an incorrect consent. Anesthesia chose to go in ahead of nursing staff (we were still in another case) and give the man a shoulder block - he was to receive MAC instead of a general. I get there and he's had versed, they're putting in the block and i stay to assist. What else can I do?? I look at the paperwork afterwards and the consent is for an intraop angiogram and we're doing an AV fistula revision! I have to chase down the surgeon, he CHANGES THE CONSENT and my preceptor looks at the patient and says that 'he's awake, he looks/sounds ok so we can have him initial the changes'. I ask anesthesia to reverse the versed and am told 'it's been about half an hour, he's probably ok'. I left, went to one of our coordinators whom I trust and explained what was happening and asked her advice. She was NOT happy at all with what was happening and told me to either keep my name off the paperwork or make sure to slap 'orientation' next to my name in the charting. That's all well and good but it doesn't help the patient. Granted, this guy was going to lose his arm if we didn't repair the fistula but still....and he probably knew ahead of time what was being done...but still. I had nobody else higher to go to at the moment and by the time I could've gotten someone there the procedure would've been underway. sigh...

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Specializes in ED, ICU, PSYCH, PP, CEN.

Don't change a thing Tazzi. I'd rather have a doc laughing at me than end up in court saying "everyone else does it". My coworkers laugh at me quite a bit. But in a nice way.

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never obtain a consent FROM A MEDICATED PATIENT. as for psychiatric patient, i believe it is only acceptable during their LUCID INTERVAL.

Suicidal pts do not have lucid/confused interval. And of course I know not to get a consent from someone who is psychotic. Most of our 5150's are suicidal. Those are the ones I'm talking about.

And thanks, Gonzo!!

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Specializes in Education, Acute, Med/Surg, Tele, etc.

I was just talking about this last night with the other nurses...and we fully agreed that we are only witnesses to the consent, but asked to get it 100% of the time! In fact, I didn't know I couldn't get it signed! They sure fooled me!

This happened when a noc nurse saw that a consent needed to be signed for a surgery in the AM, and not done. I told her that the patient knew she was going to have surgery, but didn't understand what it was going to happen afterwards! She thought a total knee would immediately take away the pain and she was going to go home that day!!!! Ummmmm, time for the surgeon to explain things...no way was I going to get that INFORMED consent signed...and told the next nurse it was up to her, but I wouldn't!

We both agreed...and I will find out at work how that all turned out...proably horribly I assume (always does) since the MD's have us have pts sign them. But no more for me! I will just have to be good at catching the MD and having them enter with paper in hand to sign...or write a note for them to get consent from their patients!!! I am sure pts have questions..and the surgeons need to answer them!!!!! (our anesthesia group does! They come up and meet the patient pre-surgery and go over any questions...great team!!!!!!!).

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The question of legality over getting an operative permit signed after a narcotic came up at work again yesterday. Of the 12 RN's, who work in the peri-operative services of the hospital, only 1 had ever heard it was legal to obtain a consent after a narcotic, the remaining 11, myself included, were taught never to do it. So I have spent many hours searching the internet for the right answer. My findings are as follows:

1. Yes it it legal. Rational: when a patient is in pain, their thinking is often clouded, relieving the pain, allows then to think clearer. 2. The surgeon is responsible for obtaining the informed consent. It is his responsibility to be sure the patient understands what the options are, the possible risks involved, and alternative treatments. 3. When the nurse witnesses a patient's signature, she attests to the correct patient signed the correct consent for the correct procedure.

Problem: after a narcotic is given, is that patient totally mentally competent?

I like what one person suggested, having 2 RNs witness the patient's signature. But may I also suggest, we remember to document our impression of the patient. "Narcotic given at 1000 for pain 10:10. Pt arouses easily, alert, orientated x3, able to answer questions without difficulty, states 'pain now 5:10 and manageable." Or, "Narcotic given at 1000, patient drowsy, unable to maintain eye contact, slow in answering questions, etc." and then have colleague co-sign our observations.

Does anyone have any other suggestions? Or do your hospitals have a policy in place to deal with obtaining a consent after a narcotic?

In a perfect setting, the operative consent should be signed well before a patient is taken to the OR holding area, but that does not always happen.:nurse:

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