Cultural diversity help

[OBnurse3]

How does your facility handle those patients that refuse male physicians and there is no female physician on-call??? We are having a problem with this at our small-ish hospital, as we have only 2 female OB/GYNs on staff, one of which is on maternity leave. Looking for input to take to the managers' meeting, becuae we are DEFFINATELY not going to "just let the nurse deliver"as our patients' are suggesting!!!!! And HOW do you handle it when the request due to religious practice rather than personal preference???

Thank you in advance!!!

[Chin up]

I appreciate all your responses. I agree that it is an administration problem, and they are working to recruit more femal OBs. However, what am I supposed to do when a pt presents in active labor and refuses a male physician and that is all I have to offer? I can't transfer an actively laboring woman, I can't send the doc in the room and I can NOT legally deliver this baby on purpose!!! (We all know precips happen) So is it possibe to hand them an AMA form and tell to get on down the road????

As for PNC, our docs are covering this THOUROUGHLY in the pre-natal visits, to the point of having the pt and husband sign a paper that states thy understand that a male might be the doc on-call and they will allow him to deliver, if they don't sign it, they must transfer care to an all female practice elswhere. The problem is they are siging these, but when the time comes, they refuse our male docs!!!

Let's face it, while it is an administration problem, if she refuses our male docs, and I can't transfer her, what are my options?? The only things I can think of are: make her sign the AMA form, or let her deliver into the bed unattended. But then what liabilities are open for there (failure to rescue) as it pertains to baby??? I know there is no "right" answer, but I just wanted to bounce this off other nurses and see if there is a possibility I am NOT thinking of

Believe me, I feel your urgency. Your are between a rock and a hard place. I honestly don't know what you should do except what we all have been saying. Insist your institution sets policy on this issue and quick. They have abdicated their responsibility. You nurses must do whatever it takes, to get a policy. The legal implications are too great. I understand they sign a waiver, I just don't think that is enough. In a court of law, these same can say, we did not understand what we were signing. You all are at risk without policy. I am surprised the MD's are not in the forefront. Only a clear policy from your institution can cover you and let you do what you were trained to do. Instead, unnecessary stress and I bet anger, not to mention alienation are what you are experiencing every time this situation arises.

As for all of your arguments, they are valid, it is just that the solution is not, black and white. Wishing you luck.

Nb- the community need to grieve this also. It may move it along, much quicker. Sending them away, AMA is dangerous to you as well as them. If a mother or baby were to die...Charges of discrimination....and on and on.

[Chin up]

One word: EMTALA

Please share as I am not familiar. Thank you.

[rn/writer, RN]

The following information was taken from the linked website.

EMTALA requires most hospitals to provide an examination and needed stabilizing treatment, without consideration of insurance coverage or ability to pay, when a patient presents to an emergency room for attention to an emergency medical condition.

http://www.emtala.com/faq.htm

4. What are the provisions for pregnant women in active labor?

Note that the determination of whether a woman in labor falls under the definition of "emergency medical condition" is determined by consideration of time factors -- whether there is adequate time to effect a "safe transfer" to another hospital before delivery. (If the woman is not in labor, that is, is not having contractions, then she does not fall under the terms of the statute unless her condition fits the general definition of "emergency medical condition" under the first paragraph for some other medical reason.)

Do all patients in active labor need to be admitted? It is common for patients to present with "false labor" or in the very early stages of true active labor, and certainly it is not necessary to admit all such patients. EMTALA clearly requires an examination ("medical screening examination") to determine the stage of labor, in order to make the determination of whether the patient has reached the level at which a safe transfer cannot be effectuated. If the patient is at the stage at which a safe transfer could be arranged, she can be discharged without a violation of EMTALA.

This can be one of the most problematic areas of application of the language of EMTALA. Since a seemingly safe and normal course of labor can suddenly take a turn for the worse, it can often be very difficult to determine precisely where the line for "safe transfer" is crossed. As with the application of the other key language of the statute, the determination of where the line is located is ultimately a medical decision.

If you are educating the patients and families during the pregnancy and having them sign documents that explain that there may only be male OB services at certain times, and if you are informing them when they arrive what is and is not available, I don't see that you can do much more.

Yes, it would be good for the hospital to recruit additional female OBs, but that still doesn't guarantee one will be present when any particular patient delivers.

If a female provider is of paramount importance--enough to place mom and baby at risk during an imminent birth--then these patients should be encouraged to seek OB practices that can accommodate their preferences. No one can demand to deliver at a specific hospital unless the birth is imminent, and then if falls on the patient/family do accept responsibility for their choices.

[sevensonnets]

I do not agree that it's up to the hospital to adapt to the religious and cultural needs of every patient. If a patient wants only female MDs and a hospital does not have female MDs, it's up to the patient to look for a hospital that does.

[NPinWCH]

Well, you can't force a patient to sign AMA anymore than you can force them to let the male doc deliver. You can offer the AMA, or if the patient isn't too far advanced offer transfer. The patient can actually request a transfer as well, but only if there is a receiving hospital that is willing to accept. Of course transfer does depend on dilation and how quickly labor is progressing, which we all know can change in minutes.

Okay, as for letting her deliver it bed while you stand there and not assist? That I think is dangerous. Not because I think delivery is innately dangerous, but because if something did happen and you were there, it's your butt on the line.

There is no way I would stand there and not do something. A prudent nurse would assist with delivery if a doctor was not in the room. I don't think you have a choice. Your situation sucks. Perhaps you need some community education. I don't know what group of people you're dealing with, but they don't seem to understand the realities of American hospitals.

Maybe if they are seeing a group it should be required for them to see EACH of the docs in the group during their pregnancy, or they can't be a patient. That way the "We don't want a male" discussion will come up prior to delivery.

[elkpark]

Maybe if they are seeing a group it should be required for them to see EACH of the docs in the group during their pregnancy, or they can't be a patient. That way the "We don't want a male" discussion will come up prior to delivery.

The OP says that the OBs are already doing that. --

As for PNC, our docs are covering this THOUROUGHLY in the pre-natal visits, to the point of having the pt and husband sign a paper that states thy understand that a male might be the doc on-call and they will allow him to deliver, if they don't sign it, they must transfer care to an all female practice elswhere. The problem is they are siging these, but when the time comes, they refuse our male docs!!!

[NPinWCH]

Right now, from what I see in the post, they are required to sign a paper saying they understand they might be delivered by a male and if they don't like it they need to find another doc. BUT what it looks like they are doing, however is signing it and then continuing to see the female provider throughout their pregnancy hoping to not have to deal with the issue. I guess the way I see it is if the male doc issue became an issue before it was close to delivery, then the patient might actually be forced to go to a different provider. So, make the patients see the male docs for prenatal care; rotate providers so the patients KNOW you mean it.

[Chin up]

I do not agree that it's up to the hospital to adapt to the religious and cultural needs of every patient. If a patient wants only female MDs and a hospital does not have female MDs, it's up to the patient to look for a hospital that does.

It's not that the hospital has to do anything. It doesn't. But if said hospital wants to remain competitive, which it does, they will have no choice. Right now, said hospital has no policy, but is insisting staff work this out without immunity. Staff has no power to handle situation. Staff is at risk as are patients. It would behoove said hospital, to address this issue, STAT.

[Elvish, BSN, DNP, RN, NP]

"We will do as much as we can to protect your privacy as well as make sure you and your baby are safe; however, the only doctor that is currently available is male. If there is still a problem, I will be glad to give you the number of my [manager/supervisor/hospital administration]."

Unless they get lots of phone calls, they might not recognize how often you are being placed in such an awkward position.

[klone, MSN, RN]

One word: EMTALA

I don't see how EMTALA would apply in this situation. YOu're not refusing to provide care. You're providing a medical transport to a facility that is able to provide care your facility cannot.

[bagladyrn, RN]

I don't see how EMTALA would apply in this situation. YOu're not refusing to provide care. You're providing a medical transport to a facility that is able to provide care your facility cannot.

You cannot transfer an active labor if they are dilated beyond a certain point with contractions and cervical change. I don't know of any transport team that would accept that patient.

To the OP - do you have a female Family Practice or ER Doc who would be willing to be the emergency backup (of last resort) for these patients?

[klone, MSN, RN]

You cannot transfer an active labor if they are dilated beyond a certain point with contractions and cervical change. I don't know of any transport team that would accept that patient.

Who specifically says you "cannot"? I'm just wondering if that's simply one hospital or transport company's policy.

Because I'm here to tell you that we have.