Ethical/Legal question

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Hi,

Here's a hypothetical question:

Patient A comes in for elective surgery (TAH BSO) and is in pre-op. Anesthesiologist sees patient and does the normal pre-anesthesia talk. Patient refuses Versed, is willing to have anything else instead, but refuses Versed verbally as well as writing this refusal on the consent form. Anesthesiologist says ok, fine. Anesthesiologist comes back with the pre-op sedative and injects it into IV. Patient starts to calm down a bit, and then asks the Anesthesiologist (who is wheeling her off to the OR) What was the drug she was given, A-man answers Midazolam, very quickly, mumbling. Patient is heard saying, "But, but, but" then she's out.

Is this legal? Is this ethical? Is it a patient's right to refuse a particular drug? I always thought that it was.....

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

I'll agree with Yoga's suggestions, too. There are ways to take action without going to the extent of a lawsuit.

I've had Versed before for surgery. It makes me talk a blue streak. I mean, I don't shut up. I don't sleep, and I can carry on a coherent conversation, but it's yakkety yakkety yak.

I really can't speak to the legalities of what happened to this lady, though I tend to think criminal charges could have been filed, but it was certainly unethical and the anesthesiologist should be called to account for it.

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My question is, is it on the anesthesia record as given?

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Ah yep. She peeked at the chart before being DC'd. It's there.

Now she needs to get the appropriate parts of the chart copied before it gets "sanitized".

YOGAcrn, Thanks for the suggestion. I think that this would be most therapeutic for her to do,and could resolve her anger and frustration over this.

Do you really think that this is assault and battery? Wow.

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I hope she realizes how well received she is , and she is not alone.

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Bottom line is....if this Anesthesiologist was so bold as to utter the word "midazolam" and push the versed despite the patients wishes, what other illegal and cavalier actions is he/she committing on a daily basis? In my 7+ years of experience, this type of mentality is a pattern. I guarantee they WILL do it again unless actions are taken, legal or not. I 100% agree with YogaCRNA. Letters must be written to the appropriate authority and what a message it will drive home when he realizes he staffed that case for free!!

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this is an interesting thread -- i had a patient the other day that insisted that she is allergic to benzodiazepines (they make her feel drunk and drowsy - that is her stated allergic reaction) - and yet she is beside herself, crying, climbing out of the stretcher - bordering on combative due to her agitation and fears.

what do you do?

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Tenesma,

You are right. This is an interesting thread. I've looked after more than my fair share of fearful, agitated, restless, anxious, demented, and psychotic patients in the unit. But this is like apples and oranges, as they say. Realistically, the surgery setting is often very different from ICU. These patients are typically just plain scared to give up control and put their life in our hands...very understandable. From my limited perspective as a student, they are USUALLY still rational and maintain reasonable cognitive function. I'm not sure what the details are of your patient scenario (whether this was an elective outpatient procedure or an inpatient with comorbid issues having surgery.) Nonetheless, if I were in similar shoes (I'm on track to be in December, 2005) I would take 5 or 10 min more of my time in pre-op to do some teaching with the patient and a family member if present. You know, the whole therapeutic conversation "You seem a little anxious and restless and I'd like to give you something to help take the edge off and make you feel more comfortable. We need to discuss together how we can calm you down...etc, etc, etc." So many times I am amazed at the reactions I get from patients just by showing a touch of genuine compassion...it establishes trust and a sense of comfort that often (not always) makes a huge difference. It's a shame the original poster didn't have this courtesy. It sounds like your patient was one of the many who don't realize the normal expected side effects so they assume they have allergies. They need to be informed. I know you probably know all of this. Trite as it may sound, this is our duty to address psychosocial needs and involve the patient in choices rather than being paternalistic and going against their wishes much like the original poster described. It was wrong for this Anesthesiologist to attempt to deceive the patient...obviously the patient remembered the incident (anterograde not retrograde, right?)

When this approach fails, can you go to plan B and head straight for either a narcotic opiod to calm them down or a light conscious sedation dose of propofol prior to inducing them? (assuming they were cooperative enough to establish IV access) Although not as optimal as BZD's, propofol does have some amnestic effects. I don't know if propofol would be used like this very often. If not, I'd notify the surgeon about the delay and evaluate my PO & IM options, as long as the patient consented ;) Benevolence, nonmaleficence, and informed consent are essential.

I may be way off track but I'd like to hear your response!

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Originally posted by icurn96

Tenesma,

You are right. This is an interesting thread. I've looked after more than my fair share of fearful, agitated, restless, anxious, demented, and psychotic patients. Frequently, patients are already chemically impaired; they may have ICU psychosis from being intubated & sedated for extended periods; they have baseline psychiatric diagnoses that exacerbate in the clinical setting. My patience does have its limits just like everyone else. But this is like apples and oranges, as they say. Realistically, the surgery setting is often very different from ICU. These patients are typically just plain scared to give up control and put their life in our hands...very understandable. From my limited perspective, they are USUALLY still rational and maintain reasonable cognitive function. I'm not sure what the details are of your patient scenario (whether this was an elective outpatient procedure or an inpatient with comorbid issues having surgery.) Nonetheless, if I were in similar shoes (I'm on track to be in December, 2005) I would take 5 or 10 min more of my time in pre-op to do some teaching with the patient and a family member if present. You know, the whole therapeutic conversation "You seem a little anxious and restless and I'd like to give you something to help take the edge off and make you feel more comfortable. We need to discuss together how we can calm you down...etc, etc, etc." So many times I am amazed at the reactions I get from patients just by showing a touch of genuine compassion...it establishes trust and a sense of comfort that often (not always) makes a huge difference. It's a shame the original poster didn't have this courtesy. It sounds like your patient was one of the many who don't realize the normal expected side effects so they assume they have allergies. They need to be informed. I know you probably know all of this. Trite as it may sound, this is our duty to address psychosocial needs and involve the patient in choices rather than being paternalistic and going against their wishes much like the original poster described. It was wrong for this Anesthesiologist to attempt to deceive the patient...obviously the patient remembered the incident (anterograde not retrograde, right?)

When this approach fails, can you go to plan B and head straight for the conscious sedation dose of propofol prior to inducing them? (assuming they were cooperative enough to establish IV access) Although not as optimal as BZD's, it does have some amnestic effects. If not, I'd notify the surgeon about the delay and evaluate my PO & IM options, as long as the patient consented ;) Benevolence, nonmaleficence, and informed consent are essential.

I may be way off track but I'd like to hear your response!

Huh??????????? This is just like rape, no means no!

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No means no to what??? In Tenesmas situation, the patient stated they had a BZD allergy meaning further evaluation and red flag giving benzodiazepines. Propofol, the last time I looked, is NOT a benzodiazepine. And as I extensively discussed, the patient would have been INFORMED of the decision and a discussion would have taken place in the pre-op holding area. The word "rape" is a little inappropriate. My suggestion to "head straight for the propofol" was merely a suggestion as an alternative agent...NOT violate the patients wishes. Please read my preceding post again.

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she told the dr not to give her Versed, he gave it, no means no.

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Again, BarbPick, nowhere did I mention administering Versed or any other benzodiazepine at all. The question at hand is how to handle Tenesma's situation with alternative options. If you will take the time to re-read mine and Tenesmas's post, maybe this will clear up the confusion. You must be referencing Sis123's initial post. I'm addressing a little different situation. Anyhow, if I were referring to Sis123, she stated the patient refused Versed, but was willing to accept another drug, hypothetically propofol. I am 100% in agreement with upholding patient rights and protecting patient safety...essentially that is what beneficence, nonmaleficence, and informed consent means...clearly the antithesis of "rape."

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This discussion brews another question....and that is, if the general anesthesia is adequate, then why is an amnestic really necessary?

Is an amnestic kind of like insurance preventing the 2% or so of patients who have some vague surgical awareness? Or is it insurance against poor anesthesia technique?

Why would an A-man jeopardize his good name just to be able to use Versed???? Why is it sooooo much better than wide selection of benzo's available?

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