Ethical/Legal question

[Sis123]

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.....

[P_RN, ADN, RN]

However you see it, does the patient have a choice?

Off topic story. My father had a brain tumor, they gave him versed when he was having an arteriogram. He went into a coma shortly thereafter.

My intellect tells me the tumor was the cause of the coma. My heart tells me I don't want Versed. It's a lovely drug I understand. But will you understand that and choose another sedative or allow me the opportunity of choosing another facility.

[subee, MSN, CRNA]

Thank you all very much for an enlightening look at medical professional thinking. I was hoping that the problem I had was not a pervasive one. Perhaps I am missing the whole point of "informed consent." From a patient's point of view it means that the patient gets to decide what procedures, if any, the medical professionals get to do! When I get back to work I will look into it. Perhaps stronger legislation is in order. One does not need to have a complete medical education to decide what treatment is acceptable. The information to make this decision is a required part of "informed consent." That's the law, here at least. I had no idea there was such a deep resentment of this. Like I said, it's been very illuminating... Thanks again.

Yes, it was wrong to give you the Versed. However, you are equally wrong to dictate the details of the anesthetic. Axillary blocks are notoriously inadequate for bone work on the arm. They're fine for soft tissue procedures and they're good ANALGECICS for bone work but often are not adequate as an ANESTHETIC. We can't have a patient screaming half-way through the procedure and moving the arm to get away from the stimulus. You have serious control issues which need to be addressed because NOTHING can be controlled completely at all times. This Versed stuff is just skirting the real issue here, which is emotional and ultimately will cause you great unhappiness. If I had complete control of the Whole World, I would have told you to go home that day and look for another surgeon that would treat you without anesthesia in the room or just fix it yourself - you said it was reduced well - I'm sure you good have come up with something. I hope you have better luck controlling nursing than you've had controlling the pharmacy profession. But I'm not being snide when I say "Get some therapy" - been there, done that and much happier now realizing that I'm not responsible for the tilt of the earth. Lighten your load.

[neveragain]

Hello again, haven't been here for a while... I have been having problems with my surgery and been told that due to the screws sticking out into the soft tissue from the reduction, that I could cut the tendons to my hand in two if I persist in using my hand. So, from beginning (Versed) to end this has been an experience. No nursing career for me, my hand is compromised. Yes I do think I need therapy for the "control" issue, which is nothing but a bad reaction to Versed. I don't want to control the world, just what happens to me! The new Doctor says that I can have IV anesthetic in my arm, with Fentanyl as the sedation agent. I didn't need Versed or a general at all. I am not the one who picked the axillery block in the first place. I wanted a regional block and no general. I like to know what is happening to me. My anesthesiologist picked the axcillery and an intrascalene block, apparently for pain relief AFTER surgery. Judging by the comments I heard while under the influence of Versed, I have good reason not to want it, not to mention the nasty and unpleasant side effects of Versed. I have been well informed (afterwards, and mostly on-line) that the axcillery block is sometimes insufficient ( depending a lot on the skill of the Doctor) and that most anesthesiologists in my area no longer use it. That being said, my arm was completely numb for almost 24 hours after release from the hospital to the point that I could have amputated it and felt nothing. So the Versed and general were for the OR staff, not me. I have such a profound distrust of anesthesiologists now that I am unwilling to take the risk of another surgery on my arm. If I could turn back the clock I would certainly have left that hospital and figured out another option. All of this could have been avoided if my anesthesiologist had presented an "informed consent" document to me, detailing what he had in mind, instead of deciding to do away with the informed consent in order to facilitate his own wishes. All of us would have been much happier!

[ali anesthesia]

I have read through all of these posts and wish to say a few things. It is most unfortunate that you had a complication that may have been related to anesthesia. But I think you are way off course in your desire to dictate anesthesia drugs and techniques, based on limited knowledge and understanding. While I understand the concept of informed consent, the anesthesiologist's biggest mistake was not refusing to do your anesthesia. It was elective surgery and he/she was under no obligation to take you on as a patient.

While I respect your right to present your situation here, I am not sure what you expect from us. I will not change my practice of doing what I think is best for my patient, totally understand that informed consents are important, but rarely are understood by the patient and do not need to learn anesthesia from a non-anesthesia professional.

Sorry to be so hard on you, but I consider this a discussion board for CRNAs or students, not disgruntled patients.

[Calvin&Hobbes]

I think it would be foolish for you not to get your arm fixed. Would you rather play the blame game, as in: 'those nasty anesthesia people have ruined my life, now I can't even use my arm, sniff'--or are you going to get on with your life?

I've had patients like you over my 30 year career; people who are convinced that they know just as much or more than the doctors, nurses, etc. They insist on running their own show, make big stinks about things, and invariably end up affecting things is a really bad way. Your comment to the effect of not needing a 'complete medical education' to make the best choices--that tells me that you think of yourself as having some medical education. Listen, you do not have any relavant medical education at all if you are just a pharm student.

You sound like one of those people who have paranoid delusions about the healthcare system....and probably most other 'systems'. What would make you think you can diagnose an adequate reduction??? You need to start getting second opinions. Your uninformed thinking does not count as a second opinion. The internet does not count as a second opinion. Talking to people, even docs, after your surgery is not a second opinion. So, unless you want to do your own surgery, suck it up and deal in an intelligent way with people who have dealt with your type of problems thousands of times. If you insist on believing that doctors and nurses are fools who have only their own interests at heart--please, treat yourself.

If you had simply said that you didn't want to get Versed and wanted to have the least anesthesia possible while still ensuring a good result, leaving it at that, I'll bet things would have gone your way. However, in the face of you having discussions with the docs about the specifics of your anesthesia, I don't blame them for labeling you a nut case and ignoring everything you said. You don't know enough about anesthesia to get to have that kind of input. There are effective ways to 'work the system' and then there are blatantly ineffective ways of doing it, and you seem to be a master at the latter....

Yes it is your body, but since you can't give yourself anesthesia nor can you set pins in your own arm, you simply do not get to call all the shots. If someone else is doing the surgery and someone else is doing the anesthesia, you simply must depend on their knowledge of their fields. It is your decision whether or not to have surgery, but once you consent to surgery, you are giving up having full control. 'Informed consent' is NOT telling them exactly what they can and can't do. And only a fool would go into surgery thinking that he was gaurenteed to be kept awake and alert during the case. I think the CRNA did you a good turn, not allowing you to be 'awake and alert' during your arm case.

[neveragain]

There are a lot of patients on this forum. The reasons you share about why the patient should not be a part of their health care team are pretty much in line with what I have dicovered from my own "team." I am sorry that you are not interested in the patients' perspective, and imply that we are too uneducated to deserve any say in what drugs and procedures are used. The idea that we can't understand an informed consent is ludicrous. The purpose of informed consent is that we DO understand. We are supposed to sign to show that we understand and agree with the procedures and accept the risk. Maybe you should be up front with your own patients and allow them the luxury of leaving. Respect is a two way street. Allegedly. What I am doing is figuring out what the prevailing attitude is about informed consent and patient partnership. Why did this happen to me? Who better to explain than nurses? One of my best friends is a nurse, but not a CRNA. She won't allow Versed to be used on her or her family. I was considering a career change to nursing, but thankfully the list was too long and I discovered that my arm and hand will not be strong enough for nursing before I paid a bunch of money. Sorry to be so hard on you, but this is an open forum and it is an ethics question...

[ali anesthesia]

I don't want to get in a contest of the wits with you, but I continue to believe you are off-base. Believe me, I understand the legal concept of informed consent and know of the multitudes of studies which show that the patient remembers very little about it.

My patients and I have a discussion about my anesthesia plan for them; a plan that is developed by considering patient pre-existing diseases, the surgical procedure, intraoperative safety and post-operative pain control. Part of my duty as a PROFESSIONAL is to educate the patient and also to learn from them. You have no idea who I am and what I tell my patients, so I would advise you to tread lightly here.

When I consider versed to be indicated, I give it; when there could be an issue of patient safety, I may use an alternative. It is an excellent drug, and like all drugs must be used as indicated and with proper monitoring of the patient. I have had patients tell me they are "allergic" to oxygen. Does this mean that I have to do their anesthetic without oxygen? Of course not.

While I agree this forum is open to the public, I believe the public should be aware that ONE person's experience, while important to them, does not mean that everyone will respond that way. When you can present evidenced-based scientific information on this topic, I will pay attention, otherwise you are simply exploiting this board to vent your own anger.

One final word, I am in a position to administer anesthesia to MANY physicians and nurses (I get a lot of request cases). They have been very accepting of my choice of anesthesia and the ones with the most knowledge and education, are the most accepting and easiest to deal with. There is a message there.

Ali Anesthesia

[Section 51]

Ali Anesthesia:

What do we expect from you? Simple:

Complete honesty and openness. Respecting my right to refuse treatment, especially something as unnecessary as Versed induced amnesia.

There is a scary pattern seen with Versed: It is often given to patients in a sneaky and sometimes forceful manner. It has happened to me, and many other people. Read the accounts on http://versedbusters.blogspot.com/.

The behavior of far too many anesthesiologists is just plain wrong, over-the-top even.

Period.

[ORNLxxx]

I am a patient and although I haven't read this thread entirely I would like to make a comment. I too feel that my right to informed consent was compromised. I was given Versed without any discussion of how it would erase my memory for the next 2 hours. Had I known this I would have asked what other options existed (ie. Valium), and whether anything was necessary as I was not experiencing anxiety. Yes, I understand that Versed acts in an additive way with other anesthetic drugs. However, can anesthesia really not be performed without Versed ? I doubt it.

As for how much I want to know - ie. "need to learn anesthesia from a non-anesthesia professional". Well, I think I should have been given options. Ie. would I rather have an anesthetic that guarantees I will be out of commission for several hours but also if there is a problem can be reversed pharmacologically, or would I rather have an anesthetic that has a much faster half life but cannot be reversed (ie. propofol). I wouild ahve chosen safety over a couple of hours of inconvenience.

I recognize my limits in terms of knowledge about anesthetic drugs and defer to the experts to give me the facts. Howeve, I, and I alone, have the right to make decisions about my treatment. I am an engineer. Give me the complication rates, give me your reccomendations, and then let ME make the decisions.

From what I know now - Versed will not be in my future. I don't know about propofol but I do know that whatever drugs that have the absolute least liklihood of killing me will be my choice. I don't give a crap whether it is convenient or whether my caregiver prefers that I not remember.

[paindoc]

What more needs to be said on this subject that hasn't already been said. This is endless repetition of the same contentions and assertions. There can be no useful discussion on this issue due to a matter of perspective.

[traumaRUs, MSN, APRN]

This thread was started in 2004 and began with a theoretical scenario. It has rambled along for 7 full pages and is now focused on individual patient experiences which borders on providing medical advice. We at All Nurses can not provide anesthesia advice anymore than we can provide medical advice. I understand your concerns about medications given to you. However, I would advise you all to bring your concerns to the your anesthesiologists of choice and proceed on.

If you feel something has been done against your will, please again bring it up to your medical provider. Take care...