Ethical dilemma at work?

[ok2bme]

I work psych, and at my facility pts may occasionally go off grounds. Upon return, we do a breathalyzer and UDS.

The doctor also ordered a pregnancy test upon return from a woman who is going on pass today. She is teeny tiny, but over the past month or she has started to look like she is pregnant. We have all noticed.

No one has said anything, as this woman is very self-conscious about her weight and has a h/o of anorexia. She is also quite defensive and labile.

The problem is that the doc verbally told the nurses to do the pregnancy test without telling the pt. Hence why he waited for us to do it with the UDS, she would not know that we are also submitted it for pregnancy.

If she is pregnant, we need to know asap. The meds she is on could potentially hurt the fetus, and she would need prenatal care.

But doing it without this woman's permission, consent, knowledge? I'm not comfortable with this.

What would you do? I'm quite nervous to go to work today...

Thanks to all who read and reply.

[klone, MSN, RN]

Do they not provide a "blanket" consent when they are admitted?

I do not have the same ethical misgivings regarding running a pregnancy test without consent as I do with running a UDS without consent. For one thing, a pregnancy test is not self-incriminating, the way a UDS would be.

Edited to change a malaprop.

[crazdmomof4]

There is also the ethical dilemma of saving or preserving the life she is possibly carrying. Can you hesitantly broach the subject with her by being vague? Just to see where her thought process is at? I don't envy you your position. Is she alert enough to reason with?

[canesdukegirl, BSN, RN]

Do they not provide a "blanket" consent when they are admitted?

I do not have the same ethical misgivings regarding running a pregnancy test without consent as I do with running a UDS without consent. For one thing, a pregnancy test is not self-incriminating, the way a UDS would be.

Edited to change a malaprop.

That was my first thought as well. She probably signed a blanket consent when she was admitted. I would try to pull up the consent forms online if you can to read through it before you return to work. You will feel better about it if you know SOMETHING.

[elkpark]

Most people consider the admission "consent to treat" form to cover lab tests (with a few specific exceptions, like HIV testing) -- usually, language to that effect is included in the form. I find that clients in the psych settings I've worked in over the years usually aren't interested in what tests we're going to run -- we inform the client that we need a urine specimen, or need to stick them for blood, for labs and that's all they want to know (of course, if someone wants to know, I provide the information).

Additionally, we routinely do urine PG tests on all females of child-bearing age we admit (including the adolescents) without telling them, specifically, that we're doing that (again, I wouldn't withhold the information if someone asked).

I'm not really clear on why this is considered a "dilemma." Do you feel the same about other lab tests that are ordered because there is some clinically relevant need for the information?

[ok2bme]

We check for PG at admission for all women of child-bearing age; we tell them that this is routine and I have never seen any woman have a problem with it. I have not seen a repeat test done unless the woman requests it.

It is an "ethical dilemma" to me because I feel that reproductive issues are the most personal issues for women..i.e. if we are infertile, have had a miscarriage, abortion, etc. I do understand that there are safety issues for mom and possibly baby at stake, which is priority #1. I guess it's the feminist in me that is uncomfortable with this, but based on the replies I am reconsidering.

And thanks, I will check for "blanket consent" documents.

[dudette10, MSN, RN]

It is an "ethical dilemma" to me because I feel that reproductive issues are the most personal issues for women..i.e. if we are infertile, have had a miscarriage, abortion, etc. I do understand that there are safety issues for mom and possibly baby at stake, which is priority #1. I guess it's the feminist in me that is uncomfortable with this, but based on the replies I am reconsidering.

I can completely understand where you are coming from with the privacy issue. However, in order to provide her with choices regarding her meds and prenatal care, she needs to know if she's pregnant in the first place! Without knowing, she has no choices. And, the longer that she doesn't know, the more her choices are limited.

Good luck to you.

[Jolie, BSN]

I have no idea whether a "blanket" consent signed at admission would cover undisclosed pregnancy testing or not.

But I question the professionalism of a psychiatric physician who would "sneak" a pregnancy test under the radar screen. If I were the patient and learned of this after the fact (whether positive or not), I would have a very hard time trusting my caregivers. I think it is important to weigh the risk of lost trust versus the benefit of information that may or may not be gained from this surreptitious test. Isn't inpatient psychiatric treatment supposed to help the patient to take responsibility for her actions and develop mutually trusting relationships? This blows that out of the water, doesn't it? Why is he unwilling to be upfront with her? I understand she has past issues with eating disorders, but shouldn't an experienced psychiatrist be able to discuss body changes without pushing a patient over the edge? If not, maybe she needs another physician.

As a nurse, I would refuse to accept a verbal order in these circumstances. Let the physician take the responsibility for writing the order, so he can't weasel out if the patient becomes irate when she learns of it.

[Kyrshamarks, BSN, RN]

The doc is not trting to "sneak" anyhting. We routinely do pregnancy tests on women in the ER without telling them. What is she is pregnant and she is getting the meds that could hurt the fetus. If the doc continues those meds and you continue to administer them thinking she may be pregnant and she is and the fetus is damaged becasue of it you are opening yourself up to a major lawsuit that you will not win. Better to know than not.

[klone, MSN, RN]

I think it's very common for blood to be drawn, or urine collected, and to tell the pt that it's for "lab tests." We generally don't tell them every single thing we're doing or testing for unless they ask. Unless it's a situation where the pt needs to give specific, special consent (such as with an HIV test or UDS), IMO it's not unethical to NOT notify them of every test that's going to be run (again, unless they ask).

WRT the pregnancy test, the purpose is to guide treatment of the pt. It's not like a UDS where you're trying to determine if the pt has engaged in illegal activity (and the results of which would have punitive actions).

[VICEDRN, BSN, RN]

I have no idea whether a "blanket" consent signed at admission would cover undisclosed pregnancy testing or not.

But I question the professionalism of a psychiatric physician who would "sneak" a pregnancy test under the radar screen. If I were the patient and learned of this after the fact (whether positive or not), I would have a very hard time trusting my caregivers. I think it is important to weigh the risk of lost trust versus the benefit of information that may or may not be gained from this surreptitious test. Isn't inpatient psychiatric treatment supposed to help the patient to take responsibility for her actions and develop mutually trusting relationships? This blows that out of the water, doesn't it? Why is he unwilling to be upfront with her? I understand she has past issues with eating disorders, but shouldn't an experienced psychiatrist be able to discuss body changes without pushing a patient over the edge? If not, maybe she needs another physician.

As a nurse, I would refuse to accept a verbal order in these circumstances. Let the physician take the responsibility for writing the order, so he can't weasel out if the patient becomes irate when she learns of it.

Agree in total with this post. I am so tired of taking care of defensive patients who come to ER ready for a fight because other healthcare professionals have well, lied to them.

Approach the topic gently as you can. Good luck!!

[TDCHIM]

The following opinion is coming from someone studying for a degree in health information management, not nursing, so take it for what it's worth (which probably isn't much):

I understand where the OP is coming from and I think Jolie raises some very important points about the potential trust issues between patient and physician with the testing scenario the OP described. Not telling a patient of every test being done in a broad scan in an ER setting or as an initial intake measure is one thing, but IMO performing a separate test for a specific reason without telling the patient is different. Moreover, the implications for a patient who has a severe psychological problem (and one that can sometimes have major roots in issues of control) seem pretty significant.

Why is the physician so unwilling to speak to the patient about this first? Is there concern about the patient deliberately trying to harm the fetus if she discovers she might be pregnant? Just because a blanket consent (if the patient did in fact sign such a document) might give the physician the right to do so doesn't make it the right move in this instance. In terms of functioning as a patient advocate, I'd probably want more information about why the physician felt it was necessary to conceal the test from the patient.